Provider Demographics
NPI:1932221058
Name:BLANK, CHERYL RAE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:RAE
Last Name:BLANK
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 1:4744 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:406-579-2427
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:406-587-4520
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT457101YA0400X
MT202103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT51011OtherBLUE CROSS - MSU
MT0000490807Medicaid
MT264349OtherNEW WEST
MT86-1155463OtherTRI CARE
MT52820OtherBLUE CROSS - PRIVATE PRAC
MT264349OtherNEW WEST
MT86-1155463OtherTRI CARE
MT0000490807Medicaid