Provider Demographics
NPI:1477904696
Name:TISSAW, SHERRY L
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:L
Last Name:TISSAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-2066
Mailing Address - Country:US
Mailing Address - Phone:701-323-5626
Mailing Address - Fax:
Practice Address - Street 1:1303 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-2066
Practice Address - Country:US
Practice Address - Phone:701-323-5626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0014894101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health