MEDICARE: SHERRY K DESSELLE PH.D.

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	103TC1900X	Counseling Psychologist	1112	LA
2	103TC1900X	Counseling Psychologist	33201	TX

General Provider Information

NPI Number	:	1619023058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERRY K DESSELLE PH.D.

Provider Business Mailing Address
First Line	:	7424 PICARDY AVE
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-4331
Country	:	US
Telephone Number	:	225-588-6348
Fax Number	:	866-438-8180

Provider Business Practice Location Address
First Line	:	7424 PICARDY AVE
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-4331
Country	:	US
Telephone Number	:	225-588-6348
Fax Number	:	866-438-8180

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

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	09/08/2010

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