Provider Demographics
NPI:1528044765
Name:ST. JOHN, SHARYL LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:SHARYL
Middle Name:LYNN
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 TREASURE ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9424
Mailing Address - Country:US
Mailing Address - Phone:269-271-1858
Mailing Address - Fax:
Practice Address - Street 1:1662 E CENTRE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-4410
Practice Address - Country:US
Practice Address - Phone:269-321-8564
Practice Address - Fax:269-321-8641
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010840061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI544987OtherVALUE OPTIONS
MI80-0-89-7097-0OtherBCBS
MI544987OtherVALUE OPTIONS