Provider Demographics
NPI:1942421987
Name:THEOHARIDIS, SHERRI YOUNG (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHERRI
Middle Name:YOUNG
Last Name:THEOHARIDIS
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 1:407 NE 76TH TERRACE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118
Mailing Address - Country:US
Mailing Address - Phone:816-436-7900
Mailing Address - Fax:816-436-0999
Practice Address - Street 1:407 NE 76TH TERRACE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118
Practice Address - Country:US
Practice Address - Phone:816-436-7900
Practice Address - Fax:816-436-0999
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003028611101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO753168731OtherFEDERAL TAX ID