MEDICARE: DEIDRE ANGELIQUE CHERRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	CB60780478

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CB60708078	OTHER	WA	CERTIFIED BEHAVIOR TECHNICIAN

General Provider Information

NPI Number	:	1922581768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIDRE ANGELIQUE CHERRY

Provider Business Mailing Address
First Line	:	300 N ARGONNE RD STE 204
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99212-2839
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 N ARGONNE RD STE 204
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99212-2839
Country	:	US
Telephone Number	:	208-699-2595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2018
Last Update Date	:	09/07/2018

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