Provider Demographics
NPI:1982130449
Name:SMITH, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:SMITH
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 1:3761 STOCKER ST STE 106
Mailing Address - Street 2:
Mailing Address - City:VIEW PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90008-5129
Mailing Address - Country:US
Mailing Address - Phone:323-291-5003
Mailing Address - Fax:
Practice Address - Street 1:3761 STOCKER ST STE 106
Practice Address - Street 2:
Practice Address - City:VIEW PARK
Practice Address - State:CA
Practice Address - Zip Code:90008-5129
Practice Address - Country:US
Practice Address - Phone:323-832-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator