Provider Demographics
NPI:1073212296
Name:CHERRY, CANDRA JANEE
Entity Type:Individual
Prefix:
First Name:CANDRA
Middle Name:JANEE
Last Name:CHERRY
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 1:701 CARVER RD APT F25
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-8421
Mailing Address - Country:US
Mailing Address - Phone:706-938-8420
Mailing Address - Fax:
Practice Address - Street 1:701 CARVER RD APT F25
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-8421
Practice Address - Country:US
Practice Address - Phone:706-938-8420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician