1669771812 NPI number — MR. SHERMAN S STOVALL JR. LCSW-R, MA

Table of content: MR. SHERMAN S STOVALL JR. LCSW-R, MA (NPI 1669771812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669771812 NPI number — MR. SHERMAN S STOVALL JR. LCSW-R, MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOVALL
Provider First Name:
SHERMAN
Provider Middle Name:
S
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
LCSW-R, MA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669771812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
816 S BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALTA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12020-5207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-364-6632
Provider Business Mailing Address Fax Number:
518-565-0533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 CHELSEA PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLIFTON PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12065-3216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-253-4229
Provider Business Practice Location Address Fax Number:
518-565-0533
Provider Enumeration Date:
03/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  078968 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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