MEDICARE: SHERYL L GORA-BOLLOM MS

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	4303	WI

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	:	1811993314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERYL L GORA-BOLLOM MS

Provider Business Mailing Address
First Line	:	1910 SOUTH AVE
Second Line	:
City	:	LA CROSSE
State	:	WI
Zip	:	54601-5467
Country	:	US
Telephone Number	:	608-775-2287
Fax Number	:

Provider Business Practice Location Address
First Line	:	1910 SOUTH AVE
Second Line	:
City	:	LA CROSSE
State	:	WI
Zip	:	54601-5467
Country	:	US
Telephone Number	:	608-775-2287
Fax Number	:

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	10/17/2007

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