Provider Demographics
NPI:1740045533
Name:BLACK, CODY ALAN
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:ALAN
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W CASINO RD APT Y205
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-8101
Mailing Address - Country:US
Mailing Address - Phone:253-258-6908
Mailing Address - Fax:
Practice Address - Street 1:1003 7TH AVE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-5779
Practice Address - Country:US
Practice Address - Phone:142-565-8301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician