Basic Information
| Provider Information | |||||||||
| NPI: | 1467876110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISHAW | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | RAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 N D ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924103524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098840840 | ||||||||
| FaxNumber: | 9098856852 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 N D ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924103524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098840840 | ||||||||
| FaxNumber: | 9098856852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2014 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.