MEDICARE: TIM SHERRELL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS15755	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114086238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIM SHERRELL LCSW

Provider Business Mailing Address
First Line	:	PO BOX 1656
Second Line	:
City	:	LOWER LAKE
State	:	CA
Zip	:	95457
Country	:	US
Telephone Number	:	707-994-6726
Fax Number	:	707-998-3120

Provider Business Practice Location Address
First Line	:	9667 HIGHWAY 29
Second Line	:	SUITE 200
City	:	LOWER LAKE
State	:	CA
Zip	:	95457
Country	:	US
Telephone Number	:	707-994-6726
Fax Number	:	707-998-3120

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	06/07/2010

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