Provider Demographics
NPI:1992488985
Name:BLACK, KELLY (HIS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 BIENVILLE BLVD STE 7
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4358
Mailing Address - Country:US
Mailing Address - Phone:228-818-9555
Mailing Address - Fax:228-875-7493
Practice Address - Street 1:2902 BIENVILLE BLVD STE 7
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4358
Practice Address - Country:US
Practice Address - Phone:228-818-9555
Practice Address - Fax:228-875-7493
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist