Provider Demographics
NPI:1821351313
Name:BLACK, SHARLA (BS, LMT)
Entity Type:Individual
Prefix:MS
First Name:SHARLA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:BS, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4742 LIBERTY RD, #189
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-428-8279
Mailing Address - Fax:
Practice Address - Street 1:4742 LIBERTY RD S # 189
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5037
Practice Address - Country:US
Practice Address - Phone:503-428-8279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4951174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator