Healthcare Provider Details

I. General information

NPI: 1689085466
Provider Name (Legal Business Name): SEAN HEARN MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 METATE DR
SANDIA PARK NM
87047-8508
US

IV. Provider business mailing address

5 METATE DR
SANDIA PARK NM
87047-8508
US

V. Phone/Fax

Practice location:
  • Phone: 651-246-8126
  • Fax:
Mailing address:
  • Phone: 651-246-8126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number35931
License Number StateMN

VIII. Authorized Official

Name: DR. SEAN TIMOTHY HEARN
Title or Position: FAMILY MEDICINE/ PSYCHOANALYST
Credential: M.D.
Phone: 651-246-8126