Provider Demographics
NPI:1003306465
Name:BLACK, ADRIENNE NICOLE (RBT-17-45544)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:NICOLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:RBT-17-45544
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2808 FOX MEADOW LANE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404
Mailing Address - Country:US
Mailing Address - Phone:870-932-4245
Mailing Address - Fax:870-931-4457
Practice Address - Street 1:2808 FOX MEADOW LANE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404
Practice Address - Country:US
Practice Address - Phone:870-932-4245
Practice Address - Fax:870-931-4457
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-17-45544106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician