Provider Demographics
NPI:1962663294
Name:BLACK, CAROL C (SPECIALIST)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:C
Last Name:BLACK
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 PROFESSIONAL PLAZA DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-5196
Mailing Address - Country:US
Mailing Address - Phone:423-638-4158
Mailing Address - Fax:423-638-4158
Practice Address - Street 1:705 PROFESSIONAL PLAZA DR
Practice Address - Street 2:SUITE 3
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-5196
Practice Address - Country:US
Practice Address - Phone:423-638-4158
Practice Address - Fax:423-638-4158
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN515237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0184409OtherBLUE CROSS BLUE SHIELD TENNESSEE