=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619584844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN ARIENT MSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2020
-----------------------------------------------------
Last Update Date | 10/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1541 ANNEX RD
-----------------------------------------------------
City | JEFFERSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53549-9803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-674-8132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5187 CHENEY DR APT 1
-----------------------------------------------------
City | SOUTH BELOIT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61080-2074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-325-2003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 12083-120
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------