Provider Demographics
NPI:1063194546
Name:BLACK, TIANNA JADE
Entity type:Individual
Prefix:
First Name:TIANNA
Middle Name:JADE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 INDIAN TRL
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2467
Mailing Address - Country:US
Mailing Address - Phone:937-409-8020
Mailing Address - Fax:
Practice Address - Street 1:1129 MIAMISBURG CENTERVILLE RD STE 201
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-4052
Practice Address - Country:US
Practice Address - Phone:937-866-4021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator