Provider Demographics
NPI:1447785274
Name:BLACK, AMY (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 MORGAN WIELAND LN
Mailing Address - Street 2:APT 106
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2115 MORGAN WIELAND LN
Practice Address - Street 2:APT 106
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3181
Practice Address - Country:US
Practice Address - Phone:407-490-8581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-30
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47344225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist