Provider Demographics
NPI:1376524793
Name:SHERRILL, ROBERT EDWARD JR (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:SHERRILL
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5515
Mailing Address - Country:US
Mailing Address - Phone:505-327-7777
Mailing Address - Fax:505-327-7779
Practice Address - Street 1:701 W APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5515
Practice Address - Country:US
Practice Address - Phone:505-327-7777
Practice Address - Fax:505-327-7779
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM142103TC0700X
NM0013103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN7935Medicaid
NM25-0550-7Medicare ID - Type Unspecified
NMN7935Medicaid