Provider Demographics
NPI:1639561939
Name:BLACK, CHARLENE (DPT)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 CHANCE DR
Mailing Address - Street 2:
Mailing Address - City:BARNEGAT
Mailing Address - State:NJ
Mailing Address - Zip Code:08005-1338
Mailing Address - Country:US
Mailing Address - Phone:609-410-0638
Mailing Address - Fax:
Practice Address - Street 1:32 CHANCE DR
Practice Address - Street 2:
Practice Address - City:BARNEGAT
Practice Address - State:NJ
Practice Address - Zip Code:08005-1338
Practice Address - Country:US
Practice Address - Phone:609-410-0638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01188500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist