MEDICARE: SHAMIYA BLACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1508582347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAMIYA BLACK

Provider Business Mailing Address
First Line	:	11119 STEEPLE WAY BLVD APT 1308
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77065-0006
Country	:	US
Telephone Number	:	346-452-1180
Fax Number	:

Provider Business Practice Location Address
First Line	:	5109 E 5TH ST
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77493-2117
Country	:	US
Telephone Number	:	281-894-1423
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2022
Last Update Date	:	10/13/2022

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Directions to “ SHAMIYA BLACK ” Practice Location

Language	Start Address	Practice Location

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