Provider Demographics
NPI:1063247245
Name:CHEATWOOD, JUSTIN RAY
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RAY
Last Name:CHEATWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 113TH SQ NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-7700
Mailing Address - Country:US
Mailing Address - Phone:318-332-5319
Mailing Address - Fax:
Practice Address - Street 1:3401 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-3315
Practice Address - Country:US
Practice Address - Phone:612-509-7113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician