Provider Demographics
NPI:1144209537
Name:DAVERN, SHARON M (MSED)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:M
Last Name:DAVERN
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 FOX RIDGE PT
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-6406
Mailing Address - Country:US
Mailing Address - Phone:507-534-2668
Mailing Address - Fax:507-540-1290
Practice Address - Street 1:1001 14TH ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-2590
Practice Address - Country:US
Practice Address - Phone:507-534-2668
Practice Address - Fax:507-540-1290
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2103103TC0700X
TN692106H00000X
MN2106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN018669000Medicaid
MN3K149DAOtherBC/BS
MN896350900Medicaid