Provider Demographics
NPI:1003081993
Name:BLACK, MARZELLE CLAASSEN (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARZELLE
Middle Name:CLAASSEN
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 AVIGNON DR
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5120
Mailing Address - Country:US
Mailing Address - Phone:601-605-6777
Mailing Address - Fax:601-605-8869
Practice Address - Street 1:16420 W US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-8760
Practice Address - Country:US
Practice Address - Phone:719-374-6172
Practice Address - Fax:719-374-6118
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1649225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist