Provider Demographics
NPI:1649580275
Name:WISE, SHARON RENEE (LMHC)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:RENEE
Last Name:WISE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MS
Other - First Name:SHARON
Other - Middle Name:RENEE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:PO BOX 259
Mailing Address - Street 2:
Mailing Address - City:SHALLMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579
Mailing Address - Country:US
Mailing Address - Phone:850-362-6824
Mailing Address - Fax:850-362-6826
Practice Address - Street 1:44 SHELL AVENUE SE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548
Practice Address - Country:US
Practice Address - Phone:850-398-5255
Practice Address - Fax:850-689-8799
Is Sole Proprietor?:No
Enumeration Date:2010-10-17
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003493600Medicaid