Provider Demographics
NPI:1679696074
Name:BLACK, SUSAN GAIL (OTR)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAIL
Last Name:BLACK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1876 SNOWDEN AVE
Mailing Address - Street 2:REAR APT.
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38107-5119
Mailing Address - Country:US
Mailing Address - Phone:901-274-3353
Mailing Address - Fax:
Practice Address - Street 1:2120 EXETER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3922
Practice Address - Country:US
Practice Address - Phone:901-624-8677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1461225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics