Provider Demographics
NPI:1326486143
Name:BLACK, CHANEY ELIZABETH (DPT)
Entity Type:Individual
Prefix:
First Name:CHANEY
Middle Name:ELIZABETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:DPT
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 871
Mailing Address - Street 2:
Mailing Address - City:TONTITOWN
Mailing Address - State:AR
Mailing Address - Zip Code:72770-0871
Mailing Address - Country:US
Mailing Address - Phone:479-751-3900
Mailing Address - Fax:479-751-3011
Practice Address - Street 1:3061 MARKET
Practice Address - Street 2:SUITE 4
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-444-6277
Practice Address - Fax:479-444-6278
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3510225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist