Provider Demographics
NPI:1780363788
Name:EASSA, SHEILA MICHELLE
Entity type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:MICHELLE
Last Name:EASSA
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 1:2205 GRAND OAK AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-3408
Mailing Address - Country:US
Mailing Address - Phone:904-347-4248
Mailing Address - Fax:
Practice Address - Street 1:155 VO TECH DR
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:VA
Practice Address - Zip Code:24263-1233
Practice Address - Country:US
Practice Address - Phone:276-346-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0608012103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty