Provider Demographics
NPI:1417094822
Name:SHARPE, SUSANNAH B
Entity Type:Individual
Prefix:MRS
First Name:SUSANNAH
Middle Name:B
Last Name:SHARPE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSANNAH
Other - Middle Name:B
Other - Last Name:SHARPE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:P.O. BOX 51319
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33994-1116
Mailing Address - Country:US
Mailing Address - Phone:239-334-6160
Mailing Address - Fax:239-334-1339
Practice Address - Street 1:1650 MEDICAL LANE STE 4
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1119
Practice Address - Country:US
Practice Address - Phone:239-334-6160
Practice Address - Fax:239-334-1339
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
FLSA6947235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016807700Medicaid