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General NPI Number Information
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NPI Number | 1043010556
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Entity Type | Individual
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Provider Name | KYE BLACK
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Gender | Male
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Dates
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Enumeration Date | 03/14/2025
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Last Update Date | 03/14/2025
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Provider Practice Location Address
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Address Line | 528 SOUTH AVE
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City | GRETNA
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State | NE
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Zip | 68028-4500
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Country | US
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Telephone | 402-904-2612
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Fax |
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Provider Business Mailing Address
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Address Line | 209 W PAULDING RD
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City | FORT WAYNE
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State | IN
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Zip | 46807-3426
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Country | US
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Telephone | 616-368-7920
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 373H00000X
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Taxonomy Name | Day Training/Habilitation Specialist
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License Number |
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License Number State |
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