Provider Demographics
NPI:1114027828
Name:GODBOLT, SHERRIE CECILE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHERRIE
Middle Name:CECILE
Last Name:GODBOLT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15475 S PARK AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1328
Mailing Address - Country:US
Mailing Address - Phone:708-362-5084
Mailing Address - Fax:708-596-6985
Practice Address - Street 1:15475 S PARK AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1328
Practice Address - Country:US
Practice Address - Phone:708-362-5084
Practice Address - Fax:708-596-6985
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360980662084P0800X, 2084P0805X
IN01048641A2084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200197180Medicaid
IL036098066Medicaid
IL01625468OtherBCBS PROVIDER ID
IN200197180Medicaid
ILG16707Medicare UPIN
IL036098066Medicaid