Provider Demographics
NPI:1306359047
Name:GAUDIO, CHERYL (LMSW)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:
Last Name:GAUDIO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 HOOPES AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6106
Mailing Address - Country:US
Mailing Address - Phone:208-542-0352
Mailing Address - Fax:208-542-0359
Practice Address - Street 1:615 HOOPES AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-6106
Practice Address - Country:US
Practice Address - Phone:208-542-0352
Practice Address - Fax:208-542-0359
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID35379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1518097690Medicaid