Provider Demographics
NPI:1013486802
Name:CHERRY, ERIC MARIO
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:MARIO
Last Name:CHERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-2313
Mailing Address - Country:US
Mailing Address - Phone:860-707-3464
Mailing Address - Fax:
Practice Address - Street 1:49 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06053-2313
Practice Address - Country:US
Practice Address - Phone:860-707-3464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0Other0