Provider Demographics
NPI:1952655888
Name:BLACK, MICHAEL EMERY (DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EMERY
Last Name:BLACK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:MR
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:2525 SOUTH 135TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144
Mailing Address - Country:US
Mailing Address - Phone:402-333-2304
Mailing Address - Fax:
Practice Address - Street 1:2525 S 135TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2424
Practice Address - Country:US
Practice Address - Phone:402-333-2304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23142251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics