Provider Demographics
NPI:1912301532
Name:STALLWORTH, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:STALLWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3430
Mailing Address - Country:US
Mailing Address - Phone:850-855-3885
Mailing Address - Fax:
Practice Address - Street 1:235 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3430
Practice Address - Country:US
Practice Address - Phone:850-855-3885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010969771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical