Provider Demographics
NPI:1851437347
Name:BLACK, DANA M
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 SE MORRISON ST
Mailing Address - Street 2:#3
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10401 NE FOURTH PLAIN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6308
Practice Address - Country:US
Practice Address - Phone:360-892-5142
Practice Address - Fax:360-892-2157
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WATL10000766225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist