Provider Demographics
NPI:1700442613
Name:BLACK, KATHERINE MARIE (OT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARKER AVE APT 2306
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4464
Mailing Address - Country:US
Mailing Address - Phone:703-606-8730
Mailing Address - Fax:
Practice Address - Street 1:2400 MARYLAND RD STE 20
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1732
Practice Address - Country:US
Practice Address - Phone:800-321-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC016269225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist