MEDICARE: CHERYL ANN BLACK PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	647	NM
2	103TC1900X	Counseling Psychologist	647	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174650477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL ANN BLACK PH.D

Provider Business Mailing Address
First Line	:	1890 VISTA SIERRA CT
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-4653
Country	:	US
Telephone Number	:	575-639-4200
Fax Number	:	575-523-7106

Provider Business Practice Location Address
First Line	:	1890 VISTA SIERRA CT
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-4653
Country	:	US
Telephone Number	:	575-639-4200
Fax Number	:	575-523-7106

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/24/2015

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