Provider Demographics
NPI:1114391463
Name:BOARD, SHERMAN
Entity Type:Individual
Prefix:
First Name:SHERMAN
Middle Name:
Last Name:BOARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15058 ARDMORE LOOP
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-1894
Mailing Address - Country:US
Mailing Address - Phone:321-222-7524
Mailing Address - Fax:
Practice Address - Street 1:15058 ARDMORE LOOP
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-1894
Practice Address - Country:US
Practice Address - Phone:321-222-7524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603576225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant