Provider Demographics
NPI:1790855427
Name:EZOP, SHARON JEANNE (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:JEANNE
Last Name:EZOP
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 N MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3537
Mailing Address - Country:US
Mailing Address - Phone:765-287-1922
Mailing Address - Fax:
Practice Address - Street 1:526 N MARTIN AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3537
Practice Address - Country:US
Practice Address - Phone:765-287-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041859A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000345066OtherBCBS