Provider Demographics
NPI:1841824398
Name:BLACK, TORI KYM
Entity type:Individual
Prefix:
First Name:TORI
Middle Name:KYM
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TORI
Other - Middle Name:KYM
Other - Last Name:SPEAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:236 BAY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-1644
Mailing Address - Country:US
Mailing Address - Phone:650-906-0145
Mailing Address - Fax:
Practice Address - Street 1:148 WARREN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2208
Practice Address - Country:US
Practice Address - Phone:978-452-1736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW258605720OtherAETNA