Provider Demographics
NPI:1538283387
Name:BLACK, LIDA DEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LIDA
Middle Name:DEE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 ACKERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2905
Mailing Address - Country:US
Mailing Address - Phone:315-476-4822
Mailing Address - Fax:
Practice Address - Street 1:813 FAY RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-3009
Practice Address - Country:US
Practice Address - Phone:315-488-2831
Practice Address - Fax:315-488-0369
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist