Provider Demographics
NPI:1790170827
Name:SURRELL, GEROME CORNELL III
Entity Type:Individual
Prefix:MR
First Name:GEROME
Middle Name:CORNELL
Last Name:SURRELL
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 SAN CLEMENTE AVE APT 154
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-2735
Mailing Address - Country:US
Mailing Address - Phone:209-597-6796
Mailing Address - Fax:
Practice Address - Street 1:440 N EL DORADO ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1950
Practice Address - Country:US
Practice Address - Phone:209-888-4519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health