Provider Demographics
NPI:1568422533
Name:SHEARON, WALLACE SCOTT (LMFT)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:SCOTT
Last Name:SHEARON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:MR
Other - First Name:SCOTT
Other - Middle Name:W
Other - Last Name:SHEARON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:565 MEMORIAL CIR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5001
Mailing Address - Country:US
Mailing Address - Phone:386-310-8766
Mailing Address - Fax:386-310-8770
Practice Address - Street 1:565 MEMORIAL CIR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5001
Practice Address - Country:US
Practice Address - Phone:386-310-8766
Practice Address - Fax:386-310-8770
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1767101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMT1767OtherMARRIAGE AND FAMILY THERAPIST