Provider Demographics
NPI:1285133116
Name:BLACK, SETH (PT, DPT)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36397 N GANTZEL RD
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-7335
Mailing Address - Country:US
Mailing Address - Phone:480-567-2987
Mailing Address - Fax:480-347-0240
Practice Address - Street 1:36397 N GANTZEL RD
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7335
Practice Address - Country:US
Practice Address - Phone:480-567-2987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist