Provider Demographics
NPI:1154529592
Name:SYLIVANT, SHARTRA (MA, LPA)
Entity type:Individual
Prefix:MS
First Name:SHARTRA
Middle Name:
Last Name:SYLIVANT
Suffix:
Gender:F
Credentials:MA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 HOPE DR NW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-1151
Mailing Address - Country:US
Mailing Address - Phone:252-291-0415
Mailing Address - Fax:
Practice Address - Street 1:100 GOLD ST NE
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4020
Practice Address - Country:US
Practice Address - Phone:252-206-4232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1584103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107368Medicaid