Provider Demographics
NPI:1528506771
Name:KLASSEN, SEAN ALEXANDER (AGENCY AFFLIATED COU)
Entity type:Individual
Prefix:MR
First Name:SEAN
Middle Name:ALEXANDER
Last Name:KLASSEN
Suffix:
Gender:M
Credentials:AGENCY AFFLIATED COU
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1181 GARDEN LANE
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1181 GARDEN DR
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1024
Practice Address - Country:US
Practice Address - Phone:360-303-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60687418106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician