Provider Demographics
NPI:1164782983
Name:MADDALENA, CHERYL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:
Last Name:MADDALENA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5038
Mailing Address - Country:US
Mailing Address - Phone:208-447-6835
Mailing Address - Fax:
Practice Address - Street 1:1412 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5038
Practice Address - Country:US
Practice Address - Phone:208-447-6835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-26
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY - 202518103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist