Provider Demographics
NPI:1396479655
Name:MCDONALD, SEAN R
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:R
Last Name:MCDONALD
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 1:96 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-2551
Mailing Address - Country:US
Mailing Address - Phone:201-920-9328
Mailing Address - Fax:
Practice Address - Street 1:111 ROUTE 35
Practice Address - Street 2:
Practice Address - City:CLIFFWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07721-1512
Practice Address - Country:US
Practice Address - Phone:732-727-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NJ37CA00187500171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator