Provider Demographics
NPI:1508964396
Name:BLACK, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:5454 WISCONSIN AVE
Mailing Address - Street 2:SUITE 1555
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815
Mailing Address - Country:US
Mailing Address - Phone:301-951-8593
Mailing Address - Fax:301-951-8598
Practice Address - Street 1:10995 OWINGS MILLS BLVD STE 210
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-1030
Practice Address - Country:US
Practice Address - Phone:410-654-2300
Practice Address - Fax:410-654-4561
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT2843225100000X
225100000X
MD19159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC2843OtherLICENSE #