Healthcare Provider Details

I. General information

NPI: 1710002076
Provider Name (Legal Business Name): SEAN ROBERT MINTZ MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 W LANCASTER BLVD
LANCASTER CA
93534-2305
US

IV. Provider business mailing address

907 W LANCASTER BLVD
LANCASTER CA
93534-2305
US

V. Phone/Fax

Practice location:
  • Phone: 661-726-2630
  • Fax: 661-951-8820
Mailing address:
  • Phone: 661-726-2630
  • Fax: 661-951-8820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY23654
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: