Provider Demographics
NPI:1710025085
Name:BLACK, DOUGLASS WOODROW (PT, DPT, ATC, CSCS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLASS
Middle Name:WOODROW
Last Name:BLACK
Suffix:
Gender:M
Credentials:PT, DPT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 KITTRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3889
Mailing Address - Country:US
Mailing Address - Phone:919-477-6843
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR BLDG 7503
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-526-7120
Practice Address - Fax:719-526-7072
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC06962255A2300X
COAT.00017992255A2300X
COPTL.00071352251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer