Provider Demographics
NPI:1962959635
Name:BANNON, SEAN
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:BANNON
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 1:118 TOWN FARM RD
Mailing Address - Street 2:
Mailing Address - City:MONSON
Mailing Address - State:MA
Mailing Address - Zip Code:01057-9606
Mailing Address - Country:US
Mailing Address - Phone:413-289-9663
Mailing Address - Fax:
Practice Address - Street 1:319 BEECH ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-3968
Practice Address - Country:US
Practice Address - Phone:413-540-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health