Provider Demographics
NPI:1265981039
Name:DURHAM, SHARON
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:DURHAM
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 1:5904 S COOPER ST STE 104-162
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-4494
Mailing Address - Country:US
Mailing Address - Phone:817-719-0029
Mailing Address - Fax:
Practice Address - Street 1:5904 S COOPER
Practice Address - Street 2:STE 104-PMB-162
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-7601
Practice Address - Country:US
Practice Address - Phone:682-331-2685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73562101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3635153-01Medicaid