Provider Demographics
NPI:1649839499
Name:CHEATHAM, ROBERTA DARLENE (LMSW)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:DARLENE
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:CHEATHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ROBERTA CHEATHAM
Mailing Address - Street 1:101 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14904-1737
Mailing Address - Country:US
Mailing Address - Phone:607-215-3619
Mailing Address - Fax:
Practice Address - Street 1:101 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-1737
Practice Address - Country:US
Practice Address - Phone:607-215-3619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-06
Last Update Date:2024-01-19
Deactivation Date:2020-10-21
Deactivation Code:
Reactivation Date:2024-01-19
Provider Licenses
StateLicense IDTaxonomies
NY105003-1101YP2500X
NY1050031101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty