Provider Demographics
NPI:1326680109
Name:BLACK, CHADD DAVID (LPTA)
Entity Type:Individual
Prefix:
First Name:CHADD
Middle Name:DAVID
Last Name:BLACK
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 EISENHOWER ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-2817
Mailing Address - Country:US
Mailing Address - Phone:262-210-7726
Mailing Address - Fax:
Practice Address - Street 1:1049 N EDGE TRL
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1942
Practice Address - Country:US
Practice Address - Phone:608-845-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-13
Last Update Date:2019-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI520-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant