Provider Demographics
NPI:1215326350
Name:BLACK, JULIE
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
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 1:4900 HEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-1928
Mailing Address - Country:US
Mailing Address - Phone:989-631-9670
Mailing Address - Fax:
Practice Address - Street 1:4900 HEDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-631-9670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1215326350225X00000X
MI3140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist