Healthcare Provider Details

I. General information

NPI: 1649451113
Provider Name (Legal Business Name): DONNA MARIA BLACK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 STADIUM DR
HATTIESBURG MS
39401-4156
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 601-450-0310
  • Fax: 601-450-0321
Mailing address:
  • Phone: 601-450-0310
  • Fax: 601-450-0321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC0468
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: