Provider Demographics
NPI:1093594319
Name:BLACK, MATTHEW (OTS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:OTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24731 PARA SIEMPRE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-2982
Mailing Address - Country:US
Mailing Address - Phone:541-226-7995
Mailing Address - Fax:
Practice Address - Street 1:2817 ROCK MERRITT AVENUE
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist