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General NPI Number Information
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NPI Number | 1083982045
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Entity Type | Individual
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Provider Name | TINA BLACK
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Gender | Female
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Dates
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Enumeration Date | 12/06/2011
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Last Update Date | 12/06/2011
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Provider Practice Location Address
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Address Line | 210 SPARKS DR
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City | KELSO
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State | WA
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Zip | 98626-1818
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Country | US
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Telephone | 360-431-8275
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 796
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City | KELSO
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State | WA
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Zip | 98626-0069
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Country | US
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Telephone |
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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 | 374J00000X
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Taxonomy Name | Doula
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License Number |
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License Number State |
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