Provider Demographics
NPI:1154933737
Name:BLACK, SHARON M
Entity type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:M
Last Name:BLACK
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 1:4544 COLUMBUS ST APT 1105
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-7580
Mailing Address - Country:US
Mailing Address - Phone:757-672-8583
Mailing Address - Fax:
Practice Address - Street 1:224 GREAT BRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3904
Practice Address - Country:US
Practice Address - Phone:757-672-8583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904012232101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health