Provider Demographics
NPI:1255854568
Name:SHARON DAVERN MSED, LP, LMFT, LLC
Entity Type:Organization
Organization Name:SHARON DAVERN MSED, LP, LMFT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVERN
Authorized Official - Suffix:
Authorized Official - Credentials:MSED
Authorized Official - Phone:507-534-2668
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:MANTORVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55955-0193
Mailing Address - Country:US
Mailing Address - Phone:507-259-0206
Mailing Address - Fax:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1946230Medicaid