Provider Demographics
NPI:1942466537
Name:BLACK, CAROL ANN (LMT)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1419 S 24TH CT
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-5803
Mailing Address - Country:US
Mailing Address - Phone:954-696-4978
Mailing Address - Fax:
Practice Address - Street 1:903 E CYPRESS CREEK RD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334-4116
Practice Address - Country:US
Practice Address - Phone:954-491-2225
Practice Address - Fax:954-491-6862
Is Sole Proprietor?:No
Enumeration Date:2008-08-02
Last Update Date:2008-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA33170OtherMASSAGE THERAPY LICENSE