Provider Demographics
NPI:1184049173
Name:KACK, CHERYL
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:KACK
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 1:800 E ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:BELLE PLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:56011-2182
Mailing Address - Country:US
Mailing Address - Phone:507-530-3852
Mailing Address - Fax:
Practice Address - Street 1:8170 OLD CARRIAGE COURT NORTH
Practice Address - Street 2:SUITE 200
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3169
Practice Address - Country:US
Practice Address - Phone:507-530-3852
Practice Address - Fax:952-465-3901
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-27
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health