Provider Demographics
NPI:1174650477
Name:BLACK, CHERYL ANN (PHD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 VISTA SIERRA CT
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-4653
Mailing Address - Country:US
Mailing Address - Phone:575-639-4200
Mailing Address - Fax:575-523-7106
Practice Address - Street 1:1890 VISTA SIERRA CT
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-4653
Practice Address - Country:US
Practice Address - Phone:575-639-4200
Practice Address - Fax:575-523-7106
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM647103TS0200X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ1735Medicaid