Provider Demographics
NPI:1992212153
Name:GILMORE, SHARAYE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHARAYE
Middle Name:
Last Name:GILMORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHARAYE
Other - Middle Name:
Other - Last Name:GRANDBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801
Mailing Address - Country:US
Mailing Address - Phone:573-472-7518
Mailing Address - Fax:
Practice Address - Street 1:135 PLAZA DR SUITE 102
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801
Practice Address - Country:US
Practice Address - Phone:573-472-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150278661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical