Provider Demographics
NPI:1346351053
Name:GOTTWALD, SHERYL R (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHERYL
Middle Name:R
Last Name:GOTTWALD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BALSAM LN
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NH
Mailing Address - Zip Code:03031-3054
Mailing Address - Country:US
Mailing Address - Phone:603-672-1412
Mailing Address - Fax:603-862-4511
Practice Address - Street 1:15 CONSTITUTION DR
Practice Address - Street 2:SUITE 111, INDEPENDENCE PLACE
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6042
Practice Address - Country:US
Practice Address - Phone:603-471-0198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH349174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH6601859Y0NH01Medicare UPIN