Provider Demographics
NPI:1952460453
Name:BLACK, DANA E (PT)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:E
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:DANA
Other - Middle Name:E
Other - Last Name:HILZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2312 W MAIN ST STE 117
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-4233
Mailing Address - Country:US
Mailing Address - Phone:360-687-7147
Mailing Address - Fax:360-687-2866
Practice Address - Street 1:2312 W MAIN ST STE 117
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4233
Practice Address - Country:US
Practice Address - Phone:360-687-7147
Practice Address - Fax:360-687-2866
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA188232OtherL & I
WAPT00009536OtherLICENSE NUMBER
WA8405763Medicaid
WA5772HIOtherREGENCE