MEDICARE: PHILIP R SHERIDAN LCSW

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	101YM0800X	Mental Health Counselor	LCSW-7671154	ID
2	1041C0700X	Clinical Social Worker	LCSW24911	ID
3	1041C0700X	Clinical Social Worker	LCSW-7671154	ID

General Provider Information

NPI Number	:	1619993581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP R SHERIDAN LCSW

Provider Business Mailing Address
First Line	:	161 COWCATCHER LOOP
Second Line	:
City	:	BELLEVUE
State	:	ID
Zip	:	83313-5289
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	161 COWCATCHER LOOP
Second Line	:
City	:	BELLEVUE
State	:	ID
Zip	:	83313-5289
Country	:	US
Telephone Number	:	801-884-3809
Fax Number	:

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

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	08/29/2025

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Directions to “ PHILIP R SHERIDAN LCSW” Practice Location

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