Provider Demographics
NPI:1639900665
Name:ROSS, CHEYENNE RACHEL
Entity type:Individual
Prefix:MISS
First Name:CHEYENNE
Middle Name:RACHEL
Last Name:ROSS
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 1:2477 E BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:ID
Mailing Address - Zip Code:83801-8149
Mailing Address - Country:US
Mailing Address - Phone:208-758-1768
Mailing Address - Fax:
Practice Address - Street 1:7905 N MEADOWLARK WAY STE CANDD
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-5041
Practice Address - Country:US
Practice Address - Phone:208-618-2593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician