Healthcare Provider Details

I. General information

NPI: 1811094964
Provider Name (Legal Business Name): SHARON LEE KENNY BSW, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 SW FEDERAL HWY SUITE C2B
STUART FL
34994-2925
US

IV. Provider business mailing address

PO BOX 1676
STUART FL
34995-1676
US

V. Phone/Fax

Practice location:
  • Phone: 772-221-1080
  • Fax:
Mailing address:
  • Phone: 772-221-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA 5360
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: