Provider Demographics
NPI:1386911386
Name:BLACK, WENDIE G (MA)
Entity type:Individual
Prefix:MRS
First Name:WENDIE
Middle Name:G
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3490 E. RIO VIRGIN RD.
Mailing Address - Street 2:
Mailing Address - City:LITTLEFIELD
Mailing Address - State:AZ
Mailing Address - Zip Code:86432
Mailing Address - Country:US
Mailing Address - Phone:928-347-5486
Mailing Address - Fax:928-347-5967
Practice Address - Street 1:3490 E. RIO VIRGIN RD.
Practice Address - Street 2:
Practice Address - City:LITTLEFIELD
Practice Address - State:AZ
Practice Address - Zip Code:86432
Practice Address - Country:US
Practice Address - Phone:928-347-5486
Practice Address - Fax:928-347-5967
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3041974103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool