Provider Demographics
NPI:1518159433
Name:CHERYL BLANK, PH.D., P.C.
Entity Type:Organization
Organization Name:CHERYL BLANK, PH.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:406-587-7468
Mailing Address - Street 1:4744 ITANA CIR
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-9330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 W KAGY BLVD
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6000
Practice Address - Country:US
Practice Address - Phone:406-587-7468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT202103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT52820OtherBLUE CROSS
MT000085292Other264349
MT0000490807Medicaid