Provider Demographics
NPI:1639320351
Name:MEDEROS, SHERRY (LCSW, CASAC)
Entity Type:Individual
Prefix:MS
First Name:SHERRY
Middle Name:
Last Name:MEDEROS
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-3910
Mailing Address - Country:US
Mailing Address - Phone:631-766-0489
Mailing Address - Fax:631-466-3344
Practice Address - Street 1:830 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-3910
Practice Address - Country:US
Practice Address - Phone:631-766-0489
Practice Address - Fax:631-466-3344
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070356-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02791091Medicaid