Basic Information
| Provider Information | |||||||||
| NPI: | 1003161076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEATHAM | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6545 HIGHVIEW ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481272126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136452462 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13305 REECK CT | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481953197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342252090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | MI | N | Other Service Providers | Contractor | 172V00000X | 6802087049 | MI | N | Other Service Providers | Community Health Worker | 1041C0700X | 6801101207 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.