Healthcare Provider Details

I. General information

NPI: 1891786752
Provider Name (Legal Business Name): MS. SHARON MARRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 N YELLOW SPRINGS STREET
SPRINGFIELD OH
45504-2463
US

IV. Provider business mailing address

474 N YELLOW SPRINGS STREET
SPRINGFIELD OH
45504-2463
US

V. Phone/Fax

Practice location:
  • Phone: 937-399-9500
  • Fax: 937-342-4236
Mailing address:
  • Phone: 937-399-9500
  • Fax: 937-342-4236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.892647
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0017696
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: