Provider Demographics
NPI:1972878247
Name:BLACK, LAUREN
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 JEFFERSON DR APT E
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5359
Mailing Address - Country:US
Mailing Address - Phone:845-325-9704
Mailing Address - Fax:
Practice Address - Street 1:1361 JEFFERSON DR APT E
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501
Practice Address - Country:US
Practice Address - Phone:845-325-9704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015179225X00000X
SC5643225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist