Provider Demographics
NPI:1821212515
Name:OLDER, SHARON ESTILL (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:ESTILL
Last Name:OLDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S SWOOPE AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5784
Mailing Address - Country:US
Mailing Address - Phone:407-622-0444
Mailing Address - Fax:407-699-0444
Practice Address - Street 1:125 S SWOOPE AVE STE 110
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5784
Practice Address - Country:US
Practice Address - Phone:407-622-0444
Practice Address - Fax:407-699-0444
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-00-0285103K00000X
FLPY4781103TC0700X, 103TC2200X, 103TM1800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766320000Medicaid