Provider Demographics
NPI:1124368899
Name:BLACK, DESDALIN CORNELIA (MSED, BCBA)
Entity Type:Individual
Prefix:
First Name:DESDALIN
Middle Name:CORNELIA
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 E MAIN ST
Mailing Address - Street 2:APT 2
Mailing Address - City:AYER
Mailing Address - State:MA
Mailing Address - Zip Code:01432-1605
Mailing Address - Country:US
Mailing Address - Phone:508-717-1983
Mailing Address - Fax:
Practice Address - Street 1:3 E MAIN ST
Practice Address - Street 2:APT 2
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01432-1605
Practice Address - Country:US
Practice Address - Phone:508-717-1983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst