Provider Demographics
NPI:1750631511
Name:BLACK, ABBY (RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:ABBY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 SAINT JOSEPH DR
Mailing Address - Street 2:STE 140
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2428
Mailing Address - Country:US
Mailing Address - Phone:269-369-2347
Mailing Address - Fax:
Practice Address - Street 1:511 RENAISSANCE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2180
Practice Address - Country:US
Practice Address - Phone:269-350-9789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
875262133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered