Provider Demographics
NPI:1790462539
Name:WEBSTER, SHAREATHA
Entity Type:Individual
Prefix:
First Name:SHAREATHA
Middle Name:
Last Name:WEBSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HALEDON
Mailing Address - State:NJ
Mailing Address - Zip Code:07508-2316
Mailing Address - Country:US
Mailing Address - Phone:732-810-5510
Mailing Address - Fax:
Practice Address - Street 1:11 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:NORTH HALEDON
Practice Address - State:NJ
Practice Address - Zip Code:07508-2316
Practice Address - Country:US
Practice Address - Phone:732-810-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJCPRS-50440175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist