Provider Demographics
NPI:1588833362
Name:BLACK, LAUREL DELANEY (PT)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:DELANEY
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 1:216 SCUFFLETOWN RD STE B
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-7296
Mailing Address - Country:US
Mailing Address - Phone:864-254-5899
Mailing Address - Fax:864-254-5898
Practice Address - Street 1:216 SCUFFLETOWN RD STE B
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-7296
Practice Address - Country:US
Practice Address - Phone:864-254-5899
Practice Address - Fax:864-254-5898
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist