Provider Demographics
NPI:1952725897
Name:BLACK, DANELLE (RTR, ARDMS)
Entity Type:Individual
Prefix:
First Name:DANELLE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RTR, ARDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9441 LBJ FWY
Mailing Address - Street 2:SUITE 602
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-4545
Mailing Address - Country:US
Mailing Address - Phone:469-249-1887
Mailing Address - Fax:
Practice Address - Street 1:9441 LBJ FWY
Practice Address - Street 2:SUITE 602
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-4545
Practice Address - Country:US
Practice Address - Phone:469-249-1887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101592302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization