Provider Demographics
NPI:1184984676
Name:DERROUGH, SALLY ELIZABETH
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ELIZABETH
Last Name:DERROUGH
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 1:819 WATER ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5333
Mailing Address - Country:US
Mailing Address - Phone:830-792-3300
Mailing Address - Fax:
Practice Address - Street 1:819 WATER ST
Practice Address - Street 2:SUITE 300
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5333
Practice Address - Country:US
Practice Address - Phone:830-792-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55758104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker