Provider Demographics
NPI:1639386030
Name:BLACK, SHAWN (PT)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8806 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-7708
Mailing Address - Country:US
Mailing Address - Phone:859-525-1339
Mailing Address - Fax:
Practice Address - Street 1:690 LAKEVIEW PLAZA BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-4732
Practice Address - Country:US
Practice Address - Phone:614-802-2800
Practice Address - Fax:614-802-2801
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH008681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist