Healthcare Provider Details

I. General information

NPI: 1578139200
Provider Name (Legal Business Name): SUSAN SHARP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 PLANTATION RD NE
ROANOKE VA
24012-5713
US

IV. Provider business mailing address

1332 PLANTATION RD NE
ROANOKE VA
24012-5713
US

V. Phone/Fax

Practice location:
  • Phone: 540-795-3053
  • Fax:
Mailing address:
  • Phone:
  • Fax: 850-607-6932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0134000574
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: