Provider Demographics
NPI:1497832752
Name:SHERIDAN, KRISTIN MARY (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARY
Last Name:SHERIDAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 RIVER OAK DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9301
Mailing Address - Country:US
Mailing Address - Phone:989-773-6265
Mailing Address - Fax:989-773-1409
Practice Address - Street 1:1191 RIVER OAK DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-9301
Practice Address - Country:US
Practice Address - Phone:989-773-6265
Practice Address - Fax:989-773-1409
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005634103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680C745000OtherBLUE CROSS BLUE SHIELD
MI0P27920Medicare ID - Type Unspecified