Provider Demographics
NPI:1689866758
Name:BLACK, EMILY W (AP, DILP AC, LMT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:W
Last Name:BLACK
Suffix:
Gender:F
Credentials:AP, DILP AC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 NE 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-3411
Mailing Address - Country:US
Mailing Address - Phone:352-372-0689
Mailing Address - Fax:352-373-2381
Practice Address - Street 1:540 NE 5TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-3411
Practice Address - Country:US
Practice Address - Phone:352-372-0689
Practice Address - Fax:352-373-2381
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA10518225700000X
FLAP499171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist