Healthcare Provider Details

I. General information

NPI: 1578656401
Provider Name (Legal Business Name): REBECCA W CHERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W MARKET ST
BLOOMINGTON IL
61701
US

IV. Provider business mailing address

210 S GREENLEAF
BLOOMINGTON IL
61704
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-5351
  • Fax: 309-829-6808
Mailing address:
  • Phone: 309-824-9884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: