Provider Demographics
NPI:1205551413
Name:BLACK, CHASITIE RAE
Entity type:Individual
Prefix:MISS
First Name:CHASITIE
Middle Name:RAE
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 1:6501 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-4301
Mailing Address - Country:US
Mailing Address - Phone:405-812-2465
Mailing Address - Fax:
Practice Address - Street 1:6501 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-4301
Practice Address - Country:US
Practice Address - Phone:405-812-2465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist