Basic Information
| Provider Information | |||||||||
| NPI: | 1649401910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHERRY | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS, LAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAMUELS | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1015 S BROADWAY | ||||||||
| Address2: | SUITE 18 | ||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018578500 | ||||||||
| FaxNumber: | 7018578555 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 S BROADWAY | ||||||||
| Address2: | SUITE 18 | ||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018578500 | ||||||||
| FaxNumber: | 7018578555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2009 | ||||||||
| LastUpdateDate: | 08/04/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1609 | ND | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 054517 | 05 | ND | MEDICAID |