Healthcare Provider Details

I. General information

NPI: 1467902130
Provider Name (Legal Business Name): CHERYL RENEE CARTER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 S ELDORADO RD STE 102
BLOOMINGTON IL
61704-6075
US

IV. Provider business mailing address

808 S ELDORADO RD STE 102
BLOOMINGTON IL
61704-6075
US

V. Phone/Fax

Practice location:
  • Phone: 309-706-3190
  • Fax: 309-588-4115
Mailing address:
  • Phone: 309-706-3190
  • Fax: 309-588-4115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071009395
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: