Provider Demographics
NPI:1972237097
Name:DEBROUGH, CHERYL (COSMETOLOGY)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:DEBROUGH
Suffix:
Gender:F
Credentials:COSMETOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 GAUNTLET DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-2812
Mailing Address - Country:US
Mailing Address - Phone:757-606-4999
Mailing Address - Fax:
Practice Address - Street 1:4107 PORTSMOUTH BLVD STE 123
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-2140
Practice Address - Country:US
Practice Address - Phone:757-606-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
VA1201082954335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier