=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871130302
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JODY MARIE SHERWOOD LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2019
-----------------------------------------------------
Last Update Date | 12/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9440 E IRONWOOD SQUARE DR STE 101
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-4569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-750-0095
-----------------------------------------------------
Fax | 480-750-0097
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1450 E BELL RD APT 3133
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85022-2776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-828-3761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LAC-18442
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------