Provider Demographics
NPI:1275627788
Name:DEACON, SHARON RAE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:RAE
Last Name:DEACON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 NORTH VERDUGO ROAD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208
Mailing Address - Country:US
Mailing Address - Phone:818-957-5166
Mailing Address - Fax:818-249-4615
Practice Address - Street 1:3245 NORTH VERDUGO ROAD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208
Practice Address - Country:US
Practice Address - Phone:818-957-5166
Practice Address - Fax:818-249-4615
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY3453103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP3453Medicare ID - Type Unspecified