Provider Demographics
NPI:1255167797
Name:BLACK, ROBERT BENTON II (MS SLP)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:BENTON
Last Name:BLACK
Suffix:II
Gender:M
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 W RACE ST
Mailing Address - Street 2:
Mailing Address - City:ROLLING FORK
Mailing Address - State:MS
Mailing Address - Zip Code:39159-2625
Mailing Address - Country:US
Mailing Address - Phone:662-571-7667
Mailing Address - Fax:
Practice Address - Street 1:431 W RACE ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-2625
Practice Address - Country:US
Practice Address - Phone:662-795-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS5249235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist