Provider Demographics
NPI:1255795522
Name:CHEATHAM, DARYL (MHS, CSC-AD)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:CHEATHAM
Suffix:
Gender:M
Credentials:MHS, CSC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 FRANKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-4809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 GARRISON BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2335
Practice Address - Country:US
Practice Address - Phone:410-233-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSCO174101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)