Healthcare Provider Details

I. General information

NPI: 1407186869
Provider Name (Legal Business Name): PHYLLIS REGINA BLACK CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2010
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE # 359797
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

325 9TH AVE # 359797
SEATTLE WA
98104-2420
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-9612
  • Fax: 206-744-9920
Mailing address:
  • Phone: 206-744-9612
  • Fax: 206-744-9920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60097360
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: