Provider Demographics
NPI:1497460745
Name:PINE, SHERWOOD WILSON II
Entity Type:Individual
Prefix:MR
First Name:SHERWOOD
Middle Name:WILSON
Last Name:PINE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 PRESIDENT ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-4944
Mailing Address - Country:US
Mailing Address - Phone:352-478-5641
Mailing Address - Fax:
Practice Address - Street 1:1719 PRESIDENT ST
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4944
Practice Address - Country:US
Practice Address - Phone:352-478-5641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13866101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health