1255854568 NPI number — SHARON DAVERN MSED, LP, LMFT, LLC

Table of content: (NPI 1255854568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255854568 NPI number — SHARON DAVERN MSED, LP, LMFT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHARON DAVERN MSED, LP, LMFT, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255854568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 193
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANTORVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55955-0193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-259-0206
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 14TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55901-2590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-534-2668
Provider Business Practice Location Address Fax Number:
507-540-1290
Provider Enumeration Date:
07/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DAVERN
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
507-534-2668

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1946230 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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