Basic Information
Provider Information | |||||||||
NPI: | 1245248319 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHARABANI | ||||||||
FirstName: | ROBIN | ||||||||
MiddleName: | TIFFANY | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12850 FOUNTAIN SQ | ||||||||
Address2: | STE. 106 | ||||||||
City: | DAVISBURG | ||||||||
State: | MI | ||||||||
PostalCode: | 483502552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486346303 | ||||||||
FaxNumber: | 2486341746 | ||||||||
Practice Location | |||||||||
Address1: | 12850 FOUNTAIN SQ | ||||||||
Address2: | STE. 106 | ||||||||
City: | DAVISBURG | ||||||||
State: | MI | ||||||||
PostalCode: | 483502552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486346303 | ||||||||
FaxNumber: | 2486341746 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2006 | ||||||||
LastUpdateDate: | 11/02/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801081512 |   | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.