Provider Demographics
NPI:1558813048
Name:SMITH, CHERYL ELLEN (LICSW)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ELLEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:ELLEN
Other - Last Name:HODGKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0001
Mailing Address - Country:US
Mailing Address - Phone:701-234-6486
Mailing Address - Fax:
Practice Address - Street 1:720 4TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0001
Practice Address - Country:US
Practice Address - Phone:701-234-6486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND35181041C0700X
MN258061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical