Provider Demographics
NPI:1629352281
Name:MOON, SHERRY (LCSW)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:MOON
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 1:3807 BRANDON AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-1490
Mailing Address - Country:US
Mailing Address - Phone:540-776-0716
Mailing Address - Fax:540-776-0717
Practice Address - Street 1:3807 BRANDON AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1490
Practice Address - Country:US
Practice Address - Phone:540-776-0716
Practice Address - Fax:540-776-0717
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040049931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical