Provider Demographics
NPI:1003161076
Name:CHEATHAM, VICTORIA DENISE (LLMSW)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:DENISE
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6545 HIGHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2126
Mailing Address - Country:US
Mailing Address - Phone:313-645-2462
Mailing Address - Fax:
Practice Address - Street 1:13305 REECK CT
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-3197
Practice Address - Country:US
Practice Address - Phone:734-225-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171W00000X
MI6802087049172V00000X
MI68011012071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI272591342Medicare PIN