Provider Demographics
NPI:1518487594
Name:DILLE'-GOODRICH, CHERYL LYNN (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN
Last Name:DILLE'-GOODRICH
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 AUGUSTA COURSE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-2521
Mailing Address - Country:US
Mailing Address - Phone:702-580-0752
Mailing Address - Fax:
Practice Address - Street 1:163 AUGUSTA COURSE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-2521
Practice Address - Country:US
Practice Address - Phone:702-580-0752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVM-10108106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist