Healthcare Provider Details

I. General information

NPI: 1275661100
Provider Name (Legal Business Name): SEAN HARRIS ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 INDUSTRY WAY SUITE A
LYNWOOD CA
90262-4283
US

IV. Provider business mailing address

2610 INDUSTRY WAY SUITE A
LYNWOOD CA
90262-4283
US

V. Phone/Fax

Practice location:
  • Phone: 310-631-8004
  • Fax: 310-631-5875
Mailing address:
  • Phone: 310-631-8004
  • Fax: 310-631-5875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW24452
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW24452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: