Provider Demographics
NPI:1316767569
Name:DUFALL, CHEYENNE (LCSW)
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:
Last Name:DUFALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 ALGHERO DR
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-6451
Mailing Address - Country:US
Mailing Address - Phone:209-481-5014
Mailing Address - Fax:
Practice Address - Street 1:100 S JUNIPER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-2703
Practice Address - Country:US
Practice Address - Phone:415-449-2813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0250391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical