Provider Demographics
NPI:1417472184
Name:SOUTHLAND, SEAN (PHD, MDAST, CBIS)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:
Last Name:SOUTHLAND
Suffix:
Gender:M
Credentials:PHD, MDAST, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17470 N PACESETTER WAY
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-5445
Mailing Address - Country:US
Mailing Address - Phone:480-278-6609
Mailing Address - Fax:
Practice Address - Street 1:1155 W RIO SALADO PKWY STE 101
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-2826
Practice Address - Country:US
Practice Address - Phone:480-696-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ189092472E0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG