Healthcare Provider Details

I. General information

NPI: 1821871815
Provider Name (Legal Business Name): MS. CASSIE LEIGH BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CALVARY LN
JUDSONIA AR
72081-9324
US

IV. Provider business mailing address

12320 INTERSTATE 30
LITTLE ROCK AR
72210-7027
US

V. Phone/Fax

Practice location:
  • Phone: 501-737-4320
  • Fax:
Mailing address:
  • Phone: 501-737-4320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: