=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376906487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLENN SHERWOOD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2016
-----------------------------------------------------
Last Update Date | 04/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 N BALTIMORE AVE STE 1
-----------------------------------------------------
City | DERBY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67037-1625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-866-2882
-----------------------------------------------------
Fax | 316-866-2811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 N BALTIMORE AVE STE 1
-----------------------------------------------------
City | DERBY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67037-1625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-866-2882
-----------------------------------------------------
Fax | 316-866-2811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GLENN KEITH SHERWOOD
-----------------------------------------------------
Credential | LSCSW
-----------------------------------------------------
Telephone | 316-866-2882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 003
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 4118
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------