Provider Demographics
NPI:1093383200
Name:UBELHOR KOTYUK, CHERYL ANNE
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANNE
Last Name:UBELHOR KOTYUK
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 1:100 LONG BRANCH WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4864
Mailing Address - Country:US
Mailing Address - Phone:765-491-8142
Mailing Address - Fax:
Practice Address - Street 1:100 LONG BRANCH WAY
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4864
Practice Address - Country:US
Practice Address - Phone:765-491-8142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004171A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical