Healthcare Provider Details

I. General information

NPI: 1508393968
Provider Name (Legal Business Name): LAURIE ANN BLACK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 BAY PINES BLVD
BAY PINES FL
33744-8200
US

IV. Provider business mailing address

3250 ZEMKE AVE
TAMPA FL
33621-5023
US

V. Phone/Fax

Practice location:
  • Phone: 727-398-6111
  • Fax:
Mailing address:
  • Phone: 813-827-9170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY9834
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: