Provider Demographics
NPI:1588470827
Name:FANT, SEAN KELLEY
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:KELLEY
Last Name:FANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BERCUT DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-0131
Mailing Address - Country:US
Mailing Address - Phone:916-846-5357
Mailing Address - Fax:916-440-1514
Practice Address - Street 1:600 BERCUT DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-0131
Practice Address - Country:US
Practice Address - Phone:916-846-5357
Practice Address - Fax:916-440-1514
Is Sole Proprietor?:No
Enumeration Date:2024-12-10
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health