Provider Demographics
NPI:1982890844
Name:BLACK, STACY RENEE (MS,PT)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:RENEE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9108 LOS ARBOLES AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1267
Mailing Address - Country:US
Mailing Address - Phone:505-508-8589
Mailing Address - Fax:505-294-4552
Practice Address - Street 1:9108 LOS ARBOLES AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1267
Practice Address - Country:US
Practice Address - Phone:505-508-8589
Practice Address - Fax:505-294-4552
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist