Provider Demographics
NPI:1689259095
Name:KOVACH, CHEYENNE BROOKE
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:BROOKE
Last Name:KOVACH
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 1:802 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:BRACKENRIDGE
Mailing Address - State:PA
Mailing Address - Zip Code:15014-1112
Mailing Address - Country:US
Mailing Address - Phone:814-691-0912
Mailing Address - Fax:
Practice Address - Street 1:353 N DUFFY RD
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-1138
Practice Address - Country:US
Practice Address - Phone:878-271-6542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC012808101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional