Provider Demographics
NPI:1770979080
Name:BLACK, LAURA ELENA (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELENA
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 SHOREVIEW CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78732-2233
Mailing Address - Country:US
Mailing Address - Phone:512-299-4626
Mailing Address - Fax:
Practice Address - Street 1:1420 SHOREVIEW CV
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78732-2233
Practice Address - Country:US
Practice Address - Phone:512-299-4626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11688302251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics