Provider Demographics
NPI:1508392762
Name:ROBERTS, CHEYENNE
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:
Last Name:ROBERTS
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 1:2295 S. VINEYARD AVE
Mailing Address - Street 2:MOB 'D' STE 230
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761
Mailing Address - Country:US
Mailing Address - Phone:909-587-7214
Mailing Address - Fax:
Practice Address - Street 1:2295 S. VINEYARD AVE
Practice Address - Street 2:MOD 'B' STE. 230
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761
Practice Address - Country:US
Practice Address - Phone:909-724-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW66720104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker