Provider Demographics
NPI:1558541060
Name:HAVLENA, CHERI SUZZETTE (A12950)
Entity Type:Individual
Prefix:MS
First Name:CHERI
Middle Name:SUZZETTE
Last Name:HAVLENA
Suffix:
Gender:F
Credentials:A12950
Other - Prefix:
Other - First Name:SHERI
Other - Middle Name:SUZANNE
Other - Last Name:FONTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CG60497290
Mailing Address - Street 1:2705 E BURNSIDE ST STE 206
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1768
Mailing Address - Country:US
Mailing Address - Phone:360-609-6927
Mailing Address - Fax:
Practice Address - Street 1:2705 E BURNSIDE ST STE 206
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1768
Practice Address - Country:US
Practice Address - Phone:503-320-7136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60497290104100000X
ORA12950104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker