Provider Demographics
NPI:1598007247
Name:BLACK, KATELYN CARLUZZO
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:CARLUZZO
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 1:13 KENSINGTON CT
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-4054
Mailing Address - Country:US
Mailing Address - Phone:703-887-1477
Mailing Address - Fax:
Practice Address - Street 1:503 COVIL AVE STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2683
Practice Address - Country:US
Practice Address - Phone:910-792-6706
Practice Address - Fax:910-792-6737
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005888225XP0200X
NC16243225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics