Provider Demographics
NPI:1124788617
Name:SHEDD, MARIA YOORSAENG
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:YOORSAENG
Last Name:SHEDD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 EIGHTH AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:MS
Mailing Address - Zip Code:39117-3904
Mailing Address - Country:US
Mailing Address - Phone:662-364-1011
Mailing Address - Fax:
Practice Address - Street 1:402B LEGACY PARK
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4315
Practice Address - Country:US
Practice Address - Phone:769-233-7154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRBT-21-168001106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician