Provider Demographics
NPI:1699512731
Name:BLACK, SANDRA JO
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JO
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 1:408 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2306
Mailing Address - Country:US
Mailing Address - Phone:315-797-2233
Mailing Address - Fax:
Practice Address - Street 1:408 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-2306
Practice Address - Country:US
Practice Address - Phone:315-797-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY764634174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist