Provider Demographics
NPI:1568199214
Name:BLACK, DEBORAH DOMAL (PT)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:DOMAL
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:ROSE
Other - Last Name:DOMAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2628 LEGACY RDG
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-8403
Mailing Address - Country:US
Mailing Address - Phone:859-466-4923
Mailing Address - Fax:
Practice Address - Street 1:212 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-2269
Practice Address - Country:US
Practice Address - Phone:859-980-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist