Provider Demographics
NPI:1528951803
Name:BLACK, ALICEN MARIAH
Entity type:Individual
Prefix:MS
First Name:ALICEN
Middle Name:MARIAH
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 1:126 MOSSIDE LOOP
Mailing Address - Street 2:
Mailing Address - City:SEVEN FIELDS
Mailing Address - State:PA
Mailing Address - Zip Code:16046-7910
Mailing Address - Country:US
Mailing Address - Phone:551-579-0052
Mailing Address - Fax:
Practice Address - Street 1:126 MOSSIDE LOOP
Practice Address - Street 2:
Practice Address - City:SEVEN FIELDS
Practice Address - State:PA
Practice Address - Zip Code:16046-7910
Practice Address - Country:US
Practice Address - Phone:551-579-0052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61458981133V00000X
WI5281-29133V00000X
WV1595133V00000X
TXDT88876133V00000X
IN37003888A133V00000X
KS2959133V00000X
RILDN01343133V00000X
AL5236133V00000X
TN4636133V00000X
OHLD.09784133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered