Provider Demographics
NPI:1558937615
Name:FENDRICH, CHEYENNE MARIE (LADC)
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:MARIE
Last Name:FENDRICH
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GOLDFINCH CT APT 1
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-3156
Mailing Address - Country:US
Mailing Address - Phone:507-380-0580
Mailing Address - Fax:
Practice Address - Street 1:201 N BROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3569
Practice Address - Country:US
Practice Address - Phone:507-200-2624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty