Healthcare Provider Details

I. General information

NPI: 1710025085
Provider Name (Legal Business Name): DOUGLASS WOODROW BLACK PT, DPT, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR BLDG 7503
FORT CARSON CO
80913-4613
US

IV. Provider business mailing address

6426 HAWKEYE CIR
COLORADO SPRINGS CO
80919-1702
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7120
  • Fax: 719-526-7072
Mailing address:
  • Phone: 719-246-5017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0001799
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPTL.0007135
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: