Provider Demographics
NPI:1346258183
Name:BLACK, JULIE
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 LONE TREE DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-884-7880
Mailing Address - Fax:843-884-6635
Practice Address - Street 1:2061 HIGHWAY 52 SOUTH
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461
Practice Address - Country:US
Practice Address - Phone:843-761-4622
Practice Address - Fax:843-761-4625
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1753Medicaid
SCTH1760Medicaid
SCTH1760Medicaid