1720367592 NPI number — MRS. KEMBERLY SHIOBHAN SHERIDAN LPC

Table of content: MRS. KEMBERLY SHIOBHAN SHERIDAN LPC (NPI 1720367592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720367592 NPI number — MRS. KEMBERLY SHIOBHAN SHERIDAN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHERIDAN
Provider First Name:
KEMBERLY
Provider Middle Name:
SHIOBHAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

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:
1720367592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9810 MEDLOCK BRIDGE ROAD
Provider Second Line Business Mailing Address:
BLDG. B, SUITE 101
Provider Business Mailing Address City Name:
JOHNS CREEK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-680-4732
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9810 MEDLOCK BRIDGE ROAD.
Provider Second Line Business Practice Location Address:
BLDG. B, SUITE 101
Provider Business Practice Location Address City Name:
JOHNS CREEK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-680-4732
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  APC002529 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC001788 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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