Provider Demographics
NPI:1164441622
Name:ROSEN, SHERRYL J (PMHCNS-BC)
Entity Type:Individual
Prefix:
First Name:SHERRYL
Middle Name:J
Last Name:ROSEN
Suffix:
Gender:F
Credentials:PMHCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 OXFORD ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1117
Mailing Address - Country:US
Mailing Address - Phone:781-268-2200
Mailing Address - Fax:781-268-0465
Practice Address - Street 1:173 OXFORD ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1117
Practice Address - Country:US
Practice Address - Phone:781-268-2200
Practice Address - Fax:781-268-0465
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105837364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1898531Medicaid
MAS56075Medicare UPIN
MANS0255Medicare ID - Type Unspecified