Provider Demographics
NPI:1871915751
Name:SMITH, SEAN
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 42438
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-0438
Mailing Address - Country:US
Mailing Address - Phone:404-512-1703
Mailing Address - Fax:
Practice Address - Street 1:46 WESTLAND BLVD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-1218
Practice Address - Country:US
Practice Address - Phone:404-512-1703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GA352216041101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health