Provider Demographics
NPI:1194878538
Name:WHITED, SHEREL E
Entity type:Individual
Prefix:MS
First Name:SHEREL
Middle Name:E
Last Name:WHITED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHEREL
Other - Middle Name:E
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:8155 NEW MEXICO 206
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9757
Mailing Address - Country:US
Mailing Address - Phone:505-356-8265
Mailing Address - Fax:
Practice Address - Street 1:501 S ABILENE AVE
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6380
Practice Address - Country:US
Practice Address - Phone:505-359-3707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-046751041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01376713Medicaid