Provider Demographics
NPI:1629358288
Name:CERCHIONE, MICHAEL RAY
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:CERCHIONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 E. QUAIL RUN ROAD
Mailing Address - Street 2:#2
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617
Mailing Address - Country:US
Mailing Address - Phone:208-949-4479
Mailing Address - Fax:208-365-2234
Practice Address - Street 1:2007 E QUAIL RUN RD # 2
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-5059
Practice Address - Country:US
Practice Address - Phone:208-365-2525
Practice Address - Fax:208-365-2234
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDL-2382104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker