Provider Demographics
NPI:1134872674
Name:VIXAMAR, SHERLEY EDWINE
Entity type:Individual
Prefix:
First Name:SHERLEY
Middle Name:EDWINE
Last Name:VIXAMAR
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 1:782 FOXRIDGE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-5776
Mailing Address - Country:US
Mailing Address - Phone:904-637-1400
Mailing Address - Fax:904-800-4880
Practice Address - Street 1:782 FOXRIDGE CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-5776
Practice Address - Country:US
Practice Address - Phone:904-637-1400
Practice Address - Fax:904-800-4880
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-201189106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician