Healthcare Provider Details

I. General information

NPI: 1104488097
Provider Name (Legal Business Name): BRANDI SHERIDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4578 GALLIA PIKE
FRANKLIN FURNACE OH
45629-8600
US

IV. Provider business mailing address

923 FINDLAY ST
PORTSMOUTH OH
45662-4148
US

V. Phone/Fax

Practice location:
  • Phone: 740-351-0008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberQMHS
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCII.161656
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: