Healthcare Provider Details

I. General information

NPI: 1669307583
Provider Name (Legal Business Name): CHERYL MICHELE BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2026
Last Update Date: 06/13/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 FLORIDA PARK DR N
PALM COAST FL
32137-3806
US

IV. Provider business mailing address

25 FLORIDA PARK DR N
PALM COAST FL
32137-3806
US

V. Phone/Fax

Practice location:
  • Phone: 386-569-9663
  • Fax: 602-391-2379
Mailing address:
  • Phone: 386-569-9663
  • Fax: 602-391-2379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA76391
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: