Provider Demographics
NPI:1780929992
Name:CHANGLAI, SEAN (LCSW)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:CHANGLAI
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 MAXWELL LN APT 814
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-6852
Mailing Address - Country:US
Mailing Address - Phone:818-357-7565
Mailing Address - Fax:
Practice Address - Street 1:42 BROADWAY # 12-13
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-1617
Practice Address - Country:US
Practice Address - Phone:174-969-6219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC057839001041C0700X
NY085533-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1780929992Medicaid