Provider Demographics
NPI:1477025823
Name:PROVOST, SHARAYAH K (LPC)
Entity Type:Individual
Prefix:
First Name:SHARAYAH
Middle Name:K
Last Name:PROVOST
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SHARAYAH
Other - Middle Name:K
Other - Last Name:HONEYAGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:800-438-1772
Mailing Address - Fax:262-293-9737
Practice Address - Street 1:16535 W BLUEMOUND RD STE 305
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5936
Practice Address - Country:US
Practice Address - Phone:800-438-1770
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3367-226101YP2500X
WI7206-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100084565Medicaid