Healthcare Provider Details

I. General information

NPI: 1104483866
Provider Name (Legal Business Name): SEAN MCGERALD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3491 KURTZ ST UNIT 150
SAN DIEGO CA
92110-4430
US

IV. Provider business mailing address

3491 KURTZ ST UNIT 150
SAN DIEGO CA
92110-4430
US

V. Phone/Fax

Practice location:
  • Phone: 619-276-1176
  • Fax:
Mailing address:
  • Phone: 619-276-1176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW126531
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: