Healthcare Provider Details

I. General information

NPI: 1770979080
Provider Name (Legal Business Name): LAURA ELENA BLACK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 SHOREVIEW CV
AUSTIN TX
78732-2233
US

IV. Provider business mailing address

1420 SHOREVIEW CV
AUSTIN TX
78732-2233
US

V. Phone/Fax

Practice location:
  • Phone: 512-299-4626
  • Fax:
Mailing address:
  • Phone: 512-299-4626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number1168830
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: