Healthcare Provider Details

I. General information

NPI: 1750858072
Provider Name (Legal Business Name): MICHAEL R BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 RAINIER AVE S
SEATTLE WA
98144-2839
US

IV. Provider business mailing address

901 RAINIER AVE S
SEATTLE WA
98144-2839
US

V. Phone/Fax

Practice location:
  • Phone: 206-470-3880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN60417384
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP70094717
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: