Provider Demographics
NPI:1780773622
Name:BLACK, ANGELA KAY (MS, PT)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:KAY
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 BAYOU STREET
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591
Mailing Address - Country:US
Mailing Address - Phone:812-882-6972
Mailing Address - Fax:812-885-2371
Practice Address - Street 1:1019 BAYOU ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-2731
Practice Address - Country:US
Practice Address - Phone:812-882-6972
Practice Address - Fax:812-885-2371
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002671A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN441480MMedicare PIN