MEDICARE: MICHAELA BLACK PMHNP

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	163W00000X	Registered Nurse	RN.1655261	CO
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APN.1000567-NP	CO

General Provider Information

NPI Number	:	1962268607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAELA BLACK PMHNP

Provider Business Mailing Address
First Line	:	3300 N TRIUMPH BLVD STE 500
Second Line	:
City	:	LEHI
State	:	UT
Zip	:	84043-6475
Country	:	US
Telephone Number	:	801-675-8990
Fax Number	:	844-270-1824

Provider Business Practice Location Address
First Line	:	255 S ROUTT ST STE 250
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80228-2214
Country	:	US
Telephone Number	:	720-316-9778
Fax Number	:

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

Provider Enumeration Date	:	02/21/2024
Last Update Date	:	03/02/2026

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