Provider Demographics
NPI:1063412286
Name:BLACK, ANNIE (M A, P T)
Entity type:Individual
Prefix:MS
First Name:ANNIE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:M A, P T
Other - Prefix:MS
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:M A, P T
Mailing Address - Street 1:10850 71ST AVE
Mailing Address - Street 2:SUITE LL 1
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4564
Mailing Address - Country:US
Mailing Address - Phone:718-268-6072
Mailing Address - Fax:718-268-0226
Practice Address - Street 1:10850 71ST AVE
Practice Address - Street 2:SUITE LL 1
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4564
Practice Address - Country:US
Practice Address - Phone:718-268-6072
Practice Address - Fax:718-268-0226
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6044225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P376499OtherOXFORD
P376499OtherOXFORD
NYX58263Medicare UPIN