Provider Demographics
NPI:1689183105
Name:CHERRY, COLLEEN MARIE (CCLS, CT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:CHERRY
Suffix:
Gender:F
Credentials:CCLS, CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28282 RANCHO GRANDE
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-7424
Mailing Address - Country:US
Mailing Address - Phone:949-633-2197
Mailing Address - Fax:
Practice Address - Street 1:28282 RANCHO GRANDE
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-7424
Practice Address - Country:US
Practice Address - Phone:949-633-2197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
25994174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist