Provider Demographics
NPI:1326497892
Name:BLACK, LOIS (RN LMT)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:642 BELTED KINGFISHER DR N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-6257
Mailing Address - Country:US
Mailing Address - Phone:978-505-3791
Mailing Address - Fax:
Practice Address - Street 1:111 N BELCHER RD
Practice Address - Street 2:SUITE 203B
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-3257
Practice Address - Country:US
Practice Address - Phone:727-304-3790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9420096163WM1400X
FL80629225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)