Provider Demographics
NPI:1104206598
Name:BLACK, SANDRA JUEL (LMT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JUEL
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 371
Mailing Address - Street 2:
Mailing Address - City:SHELL ROCK
Mailing Address - State:IA
Mailing Address - Zip Code:50670-0371
Mailing Address - Country:US
Mailing Address - Phone:773-490-2259
Mailing Address - Fax:
Practice Address - Street 1:2052 N CLEVELAND AVE
Practice Address - Street 2:GARDEN SUITE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4505
Practice Address - Country:US
Practice Address - Phone:773-281-2225
Practice Address - Fax:773-281-2226
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.005112225700000X
IA006290225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist