Provider Demographics
NPI:1053322941
Name:TERESA BLACK, M.D. INC. P.S.
Entity Type:Organization
Organization Name:TERESA BLACK, M.D. INC. P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-255-2505
Mailing Address - Street 1:12 BELLWETHER WAY
Mailing Address - Street 2:SUITE 223
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2959
Mailing Address - Country:US
Mailing Address - Phone:360-255-2505
Mailing Address - Fax:360-255-2504
Practice Address - Street 1:12 BELLWETHER WAY
Practice Address - Street 2:SUITE 223
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2959
Practice Address - Country:US
Practice Address - Phone:360-255-2505
Practice Address - Fax:360-255-2504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8860810Medicare PIN