Provider Demographics
NPI:1003392119
Name:BLACK, SHELIA DENISE
Entity Type:Individual
Prefix:MS
First Name:SHELIA
Middle Name:DENISE
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 1:564 CYPRESS LN APT 26D
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7425
Mailing Address - Country:US
Mailing Address - Phone:662-347-3616
Mailing Address - Fax:
Practice Address - Street 1:564 CYPRESS LN APT 26D
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7425
Practice Address - Country:US
Practice Address - Phone:662-347-3616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities