Provider Demographics
NPI:1386084606
Name:DACK, CHERYL ENSOM
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ENSOM
Last Name:DACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 W LARSEN AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-6035
Mailing Address - Country:US
Mailing Address - Phone:559-999-3528
Mailing Address - Fax:
Practice Address - Street 1:40 E MINARETS AVE
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:CA
Practice Address - Zip Code:93650-1239
Practice Address - Country:US
Practice Address - Phone:559-436-0482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator