Basic Information
| Provider Information | |||||||||
| NPI: | 1841500592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUNHAM | ||||||||
| FirstName: | SEAN-MICHAEL | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | |||||||||
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| Credential: | BA PSYCH. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3290 HELEN PLACE | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074556567 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3830 S. CUSHMAN STREET | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074555304 | ||||||||
| FaxNumber: | 9074551460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2010 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MH0157 | 05 | AK | MEDICAID |