Provider Demographics
NPI:1669877585
Name:LICHTY, CHERYL LYNN (LADAC 0167681)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN
Last Name:LICHTY
Suffix:
Gender:F
Credentials:LADAC 0167681
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1078
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-1078
Mailing Address - Country:US
Mailing Address - Phone:575-524-2505
Mailing Address - Fax:
Practice Address - Street 1:715 E IDAHO AVE
Practice Address - Street 2:STE 4B
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-4703
Practice Address - Country:US
Practice Address - Phone:575-524-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLADAC 0167681101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)