Provider Demographics
NPI:1508039314
Name:REARDON, SEAN MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:MICHAEL
Last Name:REARDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11812 WAYZATA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2012
Practice Address - Country:US
Practice Address - Phone:952-922-8822
Practice Address - Fax:952-922-7222
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-12
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1612103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical