Provider Demographics
NPI:1043662489
Name:RAINEY, SHERLY
Entity type:Individual
Prefix:
First Name:SHERLY
Middle Name:
Last Name:RAINEY
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 1:16320 CAGAN WOODS APT 308
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-4996
Mailing Address - Country:US
Mailing Address - Phone:407-680-8153
Mailing Address - Fax:
Practice Address - Street 1:2113 RUBY RED BLVD STE D
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-6115
Practice Address - Country:US
Practice Address - Phone:352-394-0573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18277101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108220000Medicaid