Provider Demographics
NPI:1134344856
Name:BLACK, REBECCA SUSAN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUSAN
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 GLENDALE CT
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7143
Mailing Address - Country:US
Mailing Address - Phone:317-417-0057
Mailing Address - Fax:317-272-4049
Practice Address - Street 1:269 GLENDALE CT
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7143
Practice Address - Country:US
Practice Address - Phone:317-417-0057
Practice Address - Fax:317-272-4049
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004280A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist