Provider Demographics
NPI:1417799149
Name:BLACK, DEVIN LEVAUGHN
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:LEVAUGHN
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4137 SOUTHERN AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-6898
Mailing Address - Country:US
Mailing Address - Phone:202-905-6239
Mailing Address - Fax:
Practice Address - Street 1:4137 SOUTHERN AVE APT 303
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-6898
Practice Address - Country:US
Practice Address - Phone:202-905-6239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator