Provider Demographics
NPI:1184845687
Name:BLACK, KERRY (SLP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 S ROUTE 9W # 55
Mailing Address - Street 2:
Mailing Address - City:WEST HAVERSTRAW
Mailing Address - State:NY
Mailing Address - Zip Code:10993-1055
Mailing Address - Country:US
Mailing Address - Phone:845-786-4159
Mailing Address - Fax:
Practice Address - Street 1:51 S ROUTE 9W # 55
Practice Address - Street 2:
Practice Address - City:WEST HAVERSTRAW
Practice Address - State:NY
Practice Address - Zip Code:10993-1055
Practice Address - Country:US
Practice Address - Phone:845-786-4159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014592-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist