Provider Demographics
NPI:1669844817
Name:BLACK, CATHERINE
Entity Type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:
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:PO BOX 1540
Mailing Address - Street 2:
Mailing Address - City:GYPSUM
Mailing Address - State:CO
Mailing Address - Zip Code:81637-1540
Mailing Address - Country:US
Mailing Address - Phone:970-306-6730
Mailing Address - Fax:
Practice Address - Street 1:275 MAIN ST UNIT G-001
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-7806
Practice Address - Country:US
Practice Address - Phone:970-306-6730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002143171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist