Provider Demographics
NPI:1154455475
Name:BLACK, LORA J (OT)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:J
Last Name:BLACK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6250 FOX TAIL DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-7596
Mailing Address - Country:US
Mailing Address - Phone:937-478-6605
Mailing Address - Fax:
Practice Address - Street 1:6250 FOX TAIL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-7596
Practice Address - Country:US
Practice Address - Phone:937-478-6605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH532225X00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4176841Medicare PIN