Provider Demographics
NPI:1477290922
Name:BLACK, MARY MEGAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MEGAN
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3967 ASPEN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35475-4634
Mailing Address - Country:US
Mailing Address - Phone:205-792-5974
Mailing Address - Fax:
Practice Address - Street 1:1000 HIGHWAY 78 W
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-3655
Practice Address - Country:US
Practice Address - Phone:205-471-5713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH10809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist