Provider Demographics
NPI:1952628281
Name:BLACK, MISTY DAWN (CRT)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:BLACK
Suffix:
Gender:F
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CHANDLER WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-2935
Mailing Address - Country:US
Mailing Address - Phone:912-674-1105
Mailing Address - Fax:
Practice Address - Street 1:105 CHANDLER WAY
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-2935
Practice Address - Country:US
Practice Address - Phone:912-674-1105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified