Healthcare Provider Details

I. General information

NPI: 1750915286
Provider Name (Legal Business Name): BRITANI SHAYE BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 20TH ST STE 200
HUNTINGTON WV
25703-2071
US

IV. Provider business mailing address

1115 20TH ST STE 200
HUNTINGTON WV
25703-2071
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1500
  • Fax: 304-523-4358
Mailing address:
  • Phone: 304-691-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1247
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: