Provider Demographics
NPI:1336669613
Name:SHEIRBURN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHEIRBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 WILLIAMSON BLVD UNIT 730372
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8257
Mailing Address - Country:US
Mailing Address - Phone:386-453-1679
Mailing Address - Fax:386-200-5848
Practice Address - Street 1:260 WILLIAMSON BLVD UNIT 730372
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8257
Practice Address - Country:US
Practice Address - Phone:386-453-1679
Practice Address - Fax:386-200-5848
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSI3088OtherSTATE LICENSE