Provider Demographics
NPI:1417265059
Name:BLACK, TERESA LYN
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:LYN
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:800 NORTH SIXTH STREET
Mailing Address - Street 2:RIVERDALE ELEMENTARY SCHOOL
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53573
Mailing Address - Country:US
Mailing Address - Phone:608-739-3101
Mailing Address - Fax:
Practice Address - Street 1:800 NORTH SIXTH STREET
Practice Address - Street 2:RIVERDALE ELEMENTARY SCHOOL
Practice Address - City:MUSCODA
Practice Address - State:WI
Practice Address - Zip Code:53573
Practice Address - Country:US
Practice Address - Phone:608-739-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant