Provider Demographics
NPI:1336539527
Name:LOOMIS, CHERYL (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:
Last Name:LOOMIS
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 1:286 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4639
Mailing Address - Country:US
Mailing Address - Phone:607-373-9703
Mailing Address - Fax:315-295-2585
Practice Address - Street 1:286 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4639
Practice Address - Country:US
Practice Address - Phone:607-373-9703
Practice Address - Fax:315-295-2585
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019657103T00000X, 103TC0700X
NJ35SI00555100103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04324223Medicaid