Provider Demographics
NPI:1770851065
Name:BLACK, MICHELLE M (RD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W WELLS ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-2720
Mailing Address - Country:US
Mailing Address - Phone:414-937-2122
Mailing Address - Fax:414-937-2021
Practice Address - Street 1:2020 W WELLS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2720
Practice Address - Country:US
Practice Address - Phone:414-937-2122
Practice Address - Fax:414-937-2021
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1031883133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered