Healthcare Provider Details

I. General information

NPI: 1053149351
Provider Name (Legal Business Name): SHERROUSE PSYCHIATRY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 S WAUKESHA ST
BONIFAY FL
32425-2714
US

IV. Provider business mailing address

1913 STEVERSON RD
BONIFAY FL
32425-5601
US

V. Phone/Fax

Practice location:
  • Phone: 850-373-8002
  • Fax:
Mailing address:
  • Phone: 850-373-8002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAYLA SHERROUSE
Title or Position: OWNER
Credential: APRN
Phone: 850-373-8002