Basic Information
Provider Information | |||||||||
NPI: | 1740845064 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHERYLL | ||||||||
FirstName: | BARBARA | ||||||||
MiddleName: | RUTH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2140 BRIDGE LN | ||||||||
Address2: |   | ||||||||
City: | CUTCHOGUE | ||||||||
State: | NY | ||||||||
PostalCode: | 119351307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7555 MAIN RD | ||||||||
Address2: |   | ||||||||
City: | MATTITUCK | ||||||||
State: | NY | ||||||||
PostalCode: | 119521516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6312988642 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2019 | ||||||||
LastUpdateDate: | 05/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   |   | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 104100000X | 0781591 | NY | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X |   |   | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 078159-1 | NY | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.