Provider Demographics
NPI:1992137319
Name:BLACK, LUCY MARY
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:MARY
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:MARY
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 49
Mailing Address - Street 2:
Mailing Address - City:HOOPER BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99604-0049
Mailing Address - Country:US
Mailing Address - Phone:907-758-3500
Mailing Address - Fax:907-758-3540
Practice Address - Street 1:AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:HOOPER BAY
Practice Address - State:AK
Practice Address - Zip Code:99604-0049
Practice Address - Country:US
Practice Address - Phone:907-758-3500
Practice Address - Fax:907-758-3540
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid