Provider Demographics
NPI:1356573547
Name:FENSKE, CHEREE LOUISE (PHD)
Entity type:Individual
Prefix:
First Name:CHEREE
Middle Name:LOUISE
Last Name:FENSKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ROCK SPRING RD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06906-1954
Mailing Address - Country:US
Mailing Address - Phone:917-566-4165
Mailing Address - Fax:
Practice Address - Street 1:761 MAIN AVE STE 104
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851
Practice Address - Country:US
Practice Address - Phone:203-855-9691
Practice Address - Fax:203-855-9791
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015866103TC0700X
CT002923103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03142541Medicaid
A400016455Medicare PIN