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General NPI Number Information
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NPI Number | 1942966064
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Entity Type | Individual
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Provider Name | AUSTIN JOEL BLACK PTA
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Gender | Male
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Dates
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Enumeration Date | 11/12/2021
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Last Update Date | 11/12/2021
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Provider Practice Location Address
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Address Line | 8140 TOWNSHIP LINE RD
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City | INDIANAPOLIS
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State | IN
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Zip | 46260-5824
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Country | US
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Telephone | 317-875-9700
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Fax |
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Provider Business Mailing Address
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Address Line | 3724 KNICKERBOCKER PL APT 1D
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City | INDIANAPOLIS
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State | IN
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Zip | 46240-2186
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Country | US
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Telephone | 317-294-1584
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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 | 06006408A
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License Number State | IN
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