Healthcare Provider Details

I. General information

NPI: 1013862804
Provider Name (Legal Business Name): KYLE STEVAN BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 MARION PIKE STE 1
COAL GROVE OH
45638-2958
US

IV. Provider business mailing address

323 MARION PIKE STE 1
COAL GROVE OH
45638-2958
US

V. Phone/Fax

Practice location:
  • Phone: 740-237-4981
  • Fax:
Mailing address:
  • Phone: 740-237-4981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPRS.007899
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: