Provider Demographics
NPI:1205584786
Name:BLACK, ASHLEY DAMUDE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DAMUDE
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 1:1204 BOILING SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-4107
Mailing Address - Country:US
Mailing Address - Phone:419-612-6392
Mailing Address - Fax:
Practice Address - Street 1:2203 MARCHBANKS AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2247
Practice Address - Country:US
Practice Address - Phone:864-202-6469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4797225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant