Provider Demographics
NPI:1811568025
Name:BLACK, SAMANTHA (MA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 STARRET ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3993
Mailing Address - Country:US
Mailing Address - Phone:740-687-0042
Mailing Address - Fax:
Practice Address - Street 1:106 STOVER DR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-8601
Practice Address - Country:US
Practice Address - Phone:740-417-9265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program