Provider Demographics
NPI:1720032139
Name:BLACK, KEISHA L (RKT)
Entity Type:Individual
Prefix:MS
First Name:KEISHA
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:RKT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 SPRINGRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-3123
Mailing Address - Country:US
Mailing Address - Phone:228-497-8189
Mailing Address - Fax:
Practice Address - Street 1:1603 SPRINGRIDGE RD
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-3123
Practice Address - Country:US
Practice Address - Phone:228-497-8189
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist