Healthcare Provider Details

I. General information

NPI: 1114086238
Provider Name (Legal Business Name): TIM SHERRELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9667 HIGHWAY 29 SUITE 200
LOWER LAKE CA
95457
US

IV. Provider business mailing address

PO BOX 1656
LOWER LAKE CA
95457
US

V. Phone/Fax

Practice location:
  • Phone: 707-994-6726
  • Fax: 707-998-3120
Mailing address:
  • Phone: 707-994-6726
  • Fax: 707-998-3120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS15755
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: