MEDICARE: MS. SHERRY LYNDA ROSA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1104156462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHERRY LYNDA ROSA

Provider Business Mailing Address
First Line	:	34801 S 680 RD
Second Line	:
City	:	JAY
State	:	OK
Zip	:	74346-5412
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1629 S MAIN ST
Second Line	:
City	:	GROVE
State	:	OK
Zip	:	74344-5368
Country	:	US
Telephone Number	:	918-791-9700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2010
Last Update Date	:	01/09/2010

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