Provider Demographics
NPI:1982722575
Name:BLACK, JAMES EDWIN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWIN
Last Name:BLACK
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
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Mailing Address - Street 1:PO BOX 4065
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25364-4065
Mailing Address - Country:US
Mailing Address - Phone:304-553-2502
Mailing Address - Fax:
Practice Address - Street 1:302 CEDAR RIDGE RD
Practice Address - Street 2:
Practice Address - City:SISSONVILLE
Practice Address - State:WV
Practice Address - Zip Code:25320-9502
Practice Address - Country:US
Practice Address - Phone:304-984-0046
Practice Address - Fax:304-984-3875
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WVP.T.2477225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist