Provider Demographics
NPI:1033422605
Name:RUTHERFORD-NGOTO, CHERYL ANN
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:ANN
Last Name:RUTHERFORD-NGOTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 941692
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31141-0692
Mailing Address - Country:US
Mailing Address - Phone:404-914-1777
Mailing Address - Fax:
Practice Address - Street 1:6702 TREEHILLS PKWY
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-4605
Practice Address - Country:US
Practice Address - Phone:404-914-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-23
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA107031103K00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA107031OtherGEORGIA PROFESSIONAL CERTIFICATION