Provider Demographics
NPI:1043386220
Name:BLACK, MISTY RENAE (PTA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:RENAE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PLEASANT HILL AVE N
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3104
Mailing Address - Country:US
Mailing Address - Phone:707-829-3282
Mailing Address - Fax:707-829-3287
Practice Address - Street 1:100 PLEASANT HILL AVE N
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3104
Practice Address - Country:US
Practice Address - Phone:707-829-3282
Practice Address - Fax:707-829-3287
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6901225200000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA056831Medicare ID - Type UnspecifiedREHAB AGENCY