Provider Demographics
NPI:1447600549
Name:BLACK, FLOANNA (MA, TLLP)
Entity Type:Individual
Prefix:MRS
First Name:FLOANNA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10601 MOUNT VERNON ST APT 202
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-6910
Mailing Address - Country:US
Mailing Address - Phone:313-926-3567
Mailing Address - Fax:
Practice Address - Street 1:19853 OUTER DR STE 110
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2044
Practice Address - Country:US
Practice Address - Phone:313-406-5056
Practice Address - Fax:313-908-9181
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017194103TC0700X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical