Provider Demographics
NPI:1376851246
Name:BLACK, DENISE LEE
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:LEE
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 1:389 GREEN ST
Mailing Address - Street 2:ROOM 128
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-2013
Mailing Address - Country:US
Mailing Address - Phone:716-478-4725
Mailing Address - Fax:716-478-4730
Practice Address - Street 1:389 GREEN STREET
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094
Practice Address - Country:US
Practice Address - Phone:716-478-4925
Practice Address - Fax:716-478-4730
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002530-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant