Provider Demographics
NPI:1558824250
Name:PORCHE, CHERELLE
Entity Type:Individual
Prefix:
First Name:CHERELLE
Middle Name:
Last Name:PORCHE
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 1:12020 SOUTHERN HIGHLANDS PKWY APT 1136
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-3006
Mailing Address - Country:US
Mailing Address - Phone:702-824-6895
Mailing Address - Fax:
Practice Address - Street 1:12020 SOUTHERN HIGHLANDS PKWY APT 1136
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89141-3006
Practice Address - Country:US
Practice Address - Phone:702-824-6895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV82-4982189OtherMEDICARE
NV82-4982189Medicaid