Provider Demographics
NPI:1316754443
Name:SHARP JR, EDDIE LEE JR
Entity type:Individual
Prefix:
First Name:EDDIE
Middle Name:LEE
Last Name:SHARP JR
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 4TH ST N APT 2801
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-2746
Mailing Address - Country:US
Mailing Address - Phone:727-922-1247
Mailing Address - Fax:
Practice Address - Street 1:11601 4TH ST N APT 2801
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-2746
Practice Address - Country:US
Practice Address - Phone:727-922-1247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty