Provider Demographics
NPI:1083433445
Name:WEISMULLER, SEAN JOSEPH (SUDRC)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:JOSEPH
Last Name:WEISMULLER
Suffix:
Gender:M
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28915 THOUSAND OAKS BLVD UNIT 188
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-2108
Mailing Address - Country:US
Mailing Address - Phone:917-517-2493
Mailing Address - Fax:
Practice Address - Street 1:123 S MONTEBELLO BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4729
Practice Address - Country:US
Practice Address - Phone:917-517-2493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16392101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)