Provider Demographics
NPI:1417096785
Name:BLACK, EDNA M
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:M
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 1:110 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-2504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 W MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-2131
Practice Address - Country:US
Practice Address - Phone:731-885-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator