Provider Demographics
NPI:1639620347
Name:BLACK, ELICIA (ATC)
Entity type:Individual
Prefix:
First Name:ELICIA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 VALLEY FOREST DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77489-6005
Mailing Address - Country:US
Mailing Address - Phone:281-299-8404
Mailing Address - Fax:
Practice Address - Street 1:2518 VALLEY FOREST DR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77489-6005
Practice Address - Country:US
Practice Address - Phone:281-299-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer