Healthcare Provider Details

I. General information

NPI: 1376524793
Provider Name (Legal Business Name): ROBERT EDWARD SHERRILL JR. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W APACHE ST
FARMINGTON NM
87401-5515
US

IV. Provider business mailing address

701 W APACHE ST
FARMINGTON NM
87401-5515
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-7777
  • Fax: 505-327-7779
Mailing address:
  • Phone: 505-327-7777
  • Fax: 505-327-7779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number142
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number0013
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: