Provider Demographics
NPI:1033232657
Name:BLACK, REBECCA (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 FLINT RD SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-6031
Mailing Address - Country:US
Mailing Address - Phone:256-340-9708
Mailing Address - Fax:256-340-9624
Practice Address - Street 1:901 SOMERBY DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-3490
Practice Address - Country:US
Practice Address - Phone:251-633-4447
Practice Address - Fax:251-633-4141
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2403235Z00000X
ALS2885235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529917620Medicaid
AL1003819608OtherGROUP NPI
ALK531Medicare UPIN