Provider Demographics
NPI:1649887365
Name:BLACK, DONNA (LMT, CMRM MMP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMT, CMRM MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 JACOBS LOOP
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-1329
Mailing Address - Country:US
Mailing Address - Phone:302-397-7125
Mailing Address - Fax:
Practice Address - Street 1:3105 LIMESTONE RD STE 305
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-2156
Practice Address - Country:US
Practice Address - Phone:302-397-7125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0003922225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist