Provider Demographics
NPI:1750788022
Name:SHERRILL-MATTOX, ANEISA LYNN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ANEISA
Middle Name:LYNN
Last Name:SHERRILL-MATTOX
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 VINE ST
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-1578
Mailing Address - Country:US
Mailing Address - Phone:573-289-2167
Mailing Address - Fax:
Practice Address - Street 1:2401 BERNADETTE DR STE 201
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4672
Practice Address - Country:US
Practice Address - Phone:573-289-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110290601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490078150Medicaid