Basic Information
| Provider Information | |||||||||
| NPI: | 1477801215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHENEY | ||||||||
| FirstName: | LARESA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4320 SUNBEAM RD APT 712 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322578836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047810600 | ||||||||
| FaxNumber: | 9047810016 | ||||||||
| Practice Location | |||||||||
| Address1: | 5776 SAINT AUGUSTINE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044484700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2012 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.