Provider Demographics
NPI:1376736157
Name:CHEATHAM, ALBERT ODELL (MS, ACADC, CPS)
Entity Type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:ODELL
Last Name:CHEATHAM
Suffix:
Gender:M
Credentials:MS, ACADC, CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 LONG MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-7017
Mailing Address - Country:US
Mailing Address - Phone:850-529-3434
Mailing Address - Fax:
Practice Address - Street 1:5705 LONG MEADOW COURT
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609
Practice Address - Country:US
Practice Address - Phone:850-529-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAD05-020C101YA0400X
MS1381101YA0400X
IA05R076101YA0400X
AL339002147101YM0800X, 171M00000X
101YP2500X
MSP04-003C174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL339002147Medicaid
AL339049174Medicaid