Provider Demographics
NPI:1508903832
Name:BLACK, DEBORAH DIANNE (MA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:DIANNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35504-6341
Mailing Address - Country:US
Mailing Address - Phone:205-384-1114
Mailing Address - Fax:
Practice Address - Street 1:1909 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-6151
Practice Address - Country:US
Practice Address - Phone:256-734-4688
Practice Address - Fax:256-736-5638
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51526025OtherBCBS