Provider Demographics
NPI:1801320387
Name:BLACK, MELINDA (RBT)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 JASON MAXWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091-2018
Mailing Address - Country:US
Mailing Address - Phone:931-359-1197
Mailing Address - Fax:931-359-7705
Practice Address - Street 1:1600 JASON MAXWELL BLVD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-2018
Practice Address - Country:US
Practice Address - Phone:931-359-1197
Practice Address - Fax:931-359-7705
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-16-21913106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician