Provider Demographics
NPI:1578617502
Name:ROTHERHAM, CHERYL K (MS, LCSW)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:K
Last Name:ROTHERHAM
Suffix:
Gender:F
Credentials:MS, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 WILLARD DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5204
Mailing Address - Country:US
Mailing Address - Phone:920-497-0788
Mailing Address - Fax:920-497-0792
Practice Address - Street 1:840 WILLARD DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5204
Practice Address - Country:US
Practice Address - Phone:920-497-0788
Practice Address - Fax:920-497-0792
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1576-123106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1578617502Medicare UPIN
WI1578617502Medicare NSC