Provider Demographics
NPI:1114086238
Name:SHERRELL, TIM (LCSW)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:SHERRELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1656
Mailing Address - Street 2:
Mailing Address - City:LOWER LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95457
Mailing Address - Country:US
Mailing Address - Phone:707-994-6726
Mailing Address - Fax:707-998-3120
Practice Address - Street 1:9667 HIGHWAY 29
Practice Address - Street 2:SUITE 200
Practice Address - City:LOWER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95457
Practice Address - Country:US
Practice Address - Phone:707-994-6726
Practice Address - Fax:707-998-3120
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS157551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSW157550Medicaid
CAZZZ00351ZMedicare ID - Type Unspecified