Provider Demographics
NPI:1912349713
Name:SHERROD, THERESA (MHPP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SHERROD
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3362
Mailing Address - Country:US
Mailing Address - Phone:479-967-5570
Mailing Address - Fax:479-890-5364
Practice Address - Street 1:405 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:AR
Practice Address - Zip Code:72650
Practice Address - Country:US
Practice Address - Phone:870-448-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1707329101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health