Provider Demographics
NPI:1881743987
Name:SHERRELL, KATHLEEN E (PSYD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:E
Last Name:SHERRELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N MARION ST
Mailing Address - Street 2:#308
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1167
Mailing Address - Country:US
Mailing Address - Phone:708-386-3681
Mailing Address - Fax:709-358-1491
Practice Address - Street 1:101 N MARION ST
Practice Address - Street 2:#308
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1167
Practice Address - Country:US
Practice Address - Phone:708-386-3681
Practice Address - Fax:709-358-1491
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL571010Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER