Provider Demographics
NPI: | 1477184174 |
---|---|
Name: | JOHNSON, SHARON LEE (PHD, MED, LPC) |
Entity Type: | Individual |
Prefix: | |
First Name: | SHARON |
Middle Name: | LEE |
Last Name: | JOHNSON |
Suffix: | |
Gender: | F |
Credentials: | PHD, MED, LPC |
Other - Prefix: | |
Other - First Name: | SHEREE |
Other - Middle Name: | |
Other - Last Name: | JOHNSON |
Other - Suffix: | |
Other - Last Name Type: | Professional Name |
Other - Credentials: | PHD, MED, LPC |
Mailing Address - Street 1: | 100 CABANA CAY CIR # 1-220 |
Mailing Address - Street 2: | |
Mailing Address - City: | PANAMA CITY BEACH |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32413-4662 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 734-255-8488 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 100 CABANA CAY CIR # 1-220 |
Practice Address - Street 2: | |
Practice Address - City: | PANAMA CITY BEACH |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32413-4662 |
Practice Address - Country: | US |
Practice Address - Phone: | 734-255-8488 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2020-01-31 |
Last Update Date: | 2022-08-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
101Y00000X | ||
MI | 6401016054 | 101YP2500X, 101Y00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Single Specialty | |
No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Single Specialty |