Provider Demographics
NPI:1164652863
Name:SUMERALL, SEDETRIA (LCSW)
Entity Type:Individual
Prefix:
First Name:SEDETRIA
Middle Name:
Last Name:SUMERALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11135 FANTASY TRL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-5514
Mailing Address - Country:US
Mailing Address - Phone:502-777-2404
Mailing Address - Fax:888-607-7352
Practice Address - Street 1:3715 BARDSTOWN RD STE 300
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2268
Practice Address - Country:US
Practice Address - Phone:502-777-2404
Practice Address - Fax:888-607-7352
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100271820Medicaid