Provider Demographics
NPI:1487722815
Name:DIMMER, SHARON ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHARON
Middle Name:ANN
Last Name:DIMMER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:A
Other - Last Name:DIMMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PLLC
Mailing Address - Street 1:4211 OKEMOS RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3287
Mailing Address - Country:US
Mailing Address - Phone:517-337-9794
Mailing Address - Fax:517-579-5863
Practice Address - Street 1:4211 OKEMOS RD
Practice Address - Street 2:SUITE 8
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3287
Practice Address - Country:US
Practice Address - Phone:517-282-1191
Practice Address - Fax:517-579-5863
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007541103T00000X, 103TC0700X, 103TC2200X, 103TF0000X, 103TP2701X
MI4704075602163W00000X, 163WP0807X, 163WP0808X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI15792000OtherMAGELLAN
MI680C313790OtherBCBS OF MI
MI039180OtherVALUE OPTIONS
MI039180OtherVALUE OPTIONS
MI0P28660Medicare ID - Type UnspecifiedPART B