Provider Demographics
NPI:1114358272
Name:PAULA K. BLACK, OTR
Entity type:Organization
Organization Name:PAULA K. BLACK, OTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST, REGISTERED
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:KATHEEINE
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:214-995-4250
Mailing Address - Street 1:461 CRESTVIEW POINT DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-8349
Mailing Address - Country:US
Mailing Address - Phone:214-995-4250
Mailing Address - Fax:
Practice Address - Street 1:461 CRESTVIEW POINT DR
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-8349
Practice Address - Country:US
Practice Address - Phone:214-995-4250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109660225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3136293Medicaid