Provider Demographics
NPI:1932794450
Name:CHERRY, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CHERRY
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 1:520 SW ATLAS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-2430
Mailing Address - Country:US
Mailing Address - Phone:135-233-9584
Mailing Address - Fax:
Practice Address - Street 1:1135 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-5415
Practice Address - Country:US
Practice Address - Phone:352-339-5848
Practice Address - Fax:352-240-3919
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL843086369Medicaid