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General NPI Number Information
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NPI Number | 1326680109
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Entity Type | Individual
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Provider Name | CHADD DAVID BLACK LPTA
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Gender | Male
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Dates
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Enumeration Date | 10/13/2019
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Last Update Date | 10/13/2019
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Provider Practice Location Address
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Address Line | 1049 N EDGE TRL
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City | VERONA
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State | WI
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Zip | 53593-1942
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Country | US
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Telephone | 608-845-2100
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Fax |
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Provider Business Mailing Address
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Address Line | 4711 EISENHOWER ST
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City | OREGON
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State | WI
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Zip | 53575-2817
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Country | US
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Telephone | 262-210-7726
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 520-19
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License Number State | WI
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