Provider Demographics
NPI:1073239695
Name:ANDERSON, CHEYENNE BLU
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:BLU
Last Name:ANDERSON
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 1:16538 N MAY AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9007
Mailing Address - Country:US
Mailing Address - Phone:405-265-9309
Mailing Address - Fax:
Practice Address - Street 1:16538 N MAY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-9007
Practice Address - Country:US
Practice Address - Phone:405-265-9309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician