Provider Demographics
NPI:1871662973
Name:ROSKAM, SHERRY A (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:A
Last Name:ROSKAM
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:773 W LINCOLN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6780
Mailing Address - Country:US
Mailing Address - Phone:815-990-8210
Mailing Address - Fax:815-801-4674
Practice Address - Street 1:773 W LINCOLN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4976
Practice Address - Country:US
Practice Address - Phone:815-990-8210
Practice Address - Fax:815-801-4674
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166000462106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
05821971OtherBCBS
IL08932004OtherBCBSIL
05821971OtherBCBS