Healthcare Provider Details

I. General information

NPI: 1225592371
Provider Name (Legal Business Name): ROBYN L BLACK FEATHER CSW-PIP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 1ST STREET
WANBLEE SD
57577-0290
US

IV. Provider business mailing address

PO BOX 290
WANBLEE SD
57577-0290
US

V. Phone/Fax

Practice location:
  • Phone: 605-462-6155
  • Fax: 605-462-6631
Mailing address:
  • Phone: 605-462-6155
  • Fax: 605-462-6631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4900
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: