Healthcare Provider Details

I. General information

NPI: 1992085773
Provider Name (Legal Business Name): CHERI MCCORMACK FRESH LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10939 N BRANTLEY RD
HAYDEN ID
83835-8919
US

IV. Provider business mailing address

10939 N BRANTLEY RD
HAYDEN ID
83835-8919
US

V. Phone/Fax

Practice location:
  • Phone: 208-661-1495
  • Fax: 208-545-5222
Mailing address:
  • Phone: 208-661-1495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-5190
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: