Provider Demographics
NPI:1679081103
Name:BROWN, SHERERY ROSHELLE
Entity type:Individual
Prefix:
First Name:SHERERY
Middle Name:ROSHELLE
Last Name:BROWN
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:PO BOX 3542
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24115-3542
Mailing Address - Country:US
Mailing Address - Phone:276-618-4605
Mailing Address - Fax:276-790-3167
Practice Address - Street 1:916 BROOKDALE ST STE 2
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-3105
Practice Address - Country:US
Practice Address - Phone:276-790-3341
Practice Address - Fax:276-790-3167
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0242569520Medicaid