Provider Demographics
NPI:1154455475
Name:BLACK, LORA J (OT)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:J
Last Name:BLACK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 LITTLE YORK RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-5813
Mailing Address - Country:US
Mailing Address - Phone:937-415-9100
Mailing Address - Fax:937-415-9191
Practice Address - Street 1:4160 LITTLE YORK RD
Practice Address - Street 2:SUITE 10
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5813
Practice Address - Country:US
Practice Address - Phone:937-415-9100
Practice Address - Fax:937-415-9191
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH532225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4176841Medicare PIN