Provider Demographics
NPI:1003385162
Name:BLACK, AMY R
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 ROUTE 59 STE 102
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4910
Mailing Address - Country:US
Mailing Address - Phone:718-650-6540
Mailing Address - Fax:
Practice Address - Street 1:84 ROUTE 59 STE 102
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4910
Practice Address - Country:US
Practice Address - Phone:718-650-6540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-15-19041OtherBACB