Healthcare Provider Details

I. General information

NPI: 1144209537
Provider Name (Legal Business Name): SHARON M DAVERN MSED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 14TH ST NW
ROCHESTER MN
55901-2590
US

IV. Provider business mailing address

3 FOX RIDGE PT
TAYLORS SC
29687-6406
US

V. Phone/Fax

Practice location:
  • Phone: 507-534-2668
  • Fax: 507-540-1290
Mailing address:
  • Phone: 507-534-2668
  • Fax: 507-540-1290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP2103
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number692
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: