Provider Demographics
NPI:1669695524
Name:GAINES, CHERYL L (LCPC)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:L
Last Name:GAINES
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W FRONT ST
Mailing Address - Street 2:SUITE 400A
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5048
Mailing Address - Country:US
Mailing Address - Phone:309-828-2860
Mailing Address - Fax:309-827-2637
Practice Address - Street 1:200 W FRONT ST
Practice Address - Street 2:SUITE 400A
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5048
Practice Address - Country:US
Practice Address - Phone:309-828-2860
Practice Address - Fax:309-827-2637
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional