Provider Demographics
NPI:1891454153
Name:PROCACCINI, CHERYL A
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:A
Last Name:PROCACCINI
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 1:1278 GLENNEYRE ST # 171
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3103
Mailing Address - Country:US
Mailing Address - Phone:949-510-7666
Mailing Address - Fax:
Practice Address - Street 1:4540 CAMPUS DR STE 107
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1815
Practice Address - Country:US
Practice Address - Phone:949-510-7666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS206041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical