Provider Demographics
NPI:1649368762
Name:BLACK, EVELYN J (PTA)
Entity type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:J
Last Name:BLACK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 RIVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:33860-8322
Mailing Address - Country:US
Mailing Address - Phone:863-370-2562
Mailing Address - Fax:
Practice Address - Street 1:417 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5226
Practice Address - Country:US
Practice Address - Phone:863-688-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA18831225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA18831OtherPHYSICAL THERAPIST ASST