MEDICARE: MS. ANN SHERIDAN L.P.C.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	0704	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	02-953565-00-4	OTHER	NM	CRSID

General Provider Information

NPI Number	:	1780907139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANN SHERIDAN L.P.C.C.

Provider Business Mailing Address
First Line	:	3212 1/2 LA AVENIDA DE SAN MARCOS
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-9250
Country	:	US
Telephone Number	:	505-474-9746
Fax Number	:

Provider Business Practice Location Address
First Line	:	3212 1/2 LA AVENIDA DE SAN MARCOS
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-9250
Country	:	US
Telephone Number	:	505-474-9746
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2010
Last Update Date	:	04/12/2010

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