Provider Demographics
NPI:1679860571
Name:WEATHERLY, SHARON LEE (MSW)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:LEE
Last Name:WEATHERLY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 E STANFORD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2040
Mailing Address - Country:US
Mailing Address - Phone:417-619-9284
Mailing Address - Fax:
Practice Address - Street 1:2625 E STANFORD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2040
Practice Address - Country:US
Practice Address - Phone:417-619-9284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011024371104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker