Provider Demographics
NPI:1841500592
Name:DUNHAM, SEAN-MICHAEL RICHARD (BA PSYCH)
Entity type:Individual
Prefix:
First Name:SEAN-MICHAEL
Middle Name:RICHARD
Last Name:DUNHAM
Suffix:
Gender:M
Credentials:BA PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3290 HELEN PLACE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709
Mailing Address - Country:US
Mailing Address - Phone:907-455-6567
Mailing Address - Fax:
Practice Address - Street 1:3830 S. CUSHMAN STREET
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-455-5304
Practice Address - Fax:907-455-1460
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0157Medicaid
AKMH0157Medicaid