Provider Demographics
NPI:1952846503
Name:BLACK, BRYAN (BC-HIS, ACA)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:BC-HIS, ACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E ALEX BELL RD STE 166
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2752
Mailing Address - Country:US
Mailing Address - Phone:937-436-2358
Mailing Address - Fax:
Practice Address - Street 1:101 E ALEX BELL RD STE 166
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2752
Practice Address - Country:US
Practice Address - Phone:937-436-2358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2349237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist