Provider Demographics
NPI:1033249578
Name:MANDAVILLE, SHARON ANN (BS)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:ANN
Last Name:MANDAVILLE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 WORTH AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6856
Mailing Address - Country:US
Mailing Address - Phone:321-752-3170
Mailing Address - Fax:321-752-3179
Practice Address - Street 1:3270 SUNTREE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7532
Practice Address - Country:US
Practice Address - Phone:321-752-3170
Practice Address - Fax:321-752-3179
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL03-900001821101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health