Provider Demographics
NPI:1942536156
Name:EMMONS, CHERYL MARIE
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:MARIE
Last Name:EMMONS
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 1:515 W GARDENA BLVD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-2629
Mailing Address - Country:US
Mailing Address - Phone:310-766-0633
Mailing Address - Fax:
Practice Address - Street 1:515 W GARDENA BLVD
Practice Address - Street 2:SUITE 11
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-2629
Practice Address - Country:US
Practice Address - Phone:310-766-0633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01-090266101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)