Provider Demographics
NPI:1538230636
Name:DIMICKELE, CHERI LYNN (PSYD)
Entity type:Individual
Prefix:DR
First Name:CHERI
Middle Name:LYNN
Last Name:DIMICKELE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 MILL CREEK BLVD APT C206
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-4013
Mailing Address - Country:US
Mailing Address - Phone:920-765-1488
Mailing Address - Fax:
Practice Address - Street 1:7520 TOTEM BEACH RD
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271
Practice Address - Country:US
Practice Address - Phone:360-716-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WATE60863726103TC0700X
WI2587057103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40948000Medicare ID - Type Unspecified