Healthcare Provider Details

I. General information

NPI: 1245166735
Provider Name (Legal Business Name): MR. SEAN HUMPHREY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6842 VAN NUYS BLVD
VAN NUYS CA
91405-4650
US

IV. Provider business mailing address

702 AZALEA ST
THOUSAND OAKS CA
91360-1411
US

V. Phone/Fax

Practice location:
  • Phone: 818-994-7614
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: