MEDICARE: KATHI BLACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6151	OTHER	FL	LICENSE #

General Provider Information

NPI Number	:	1225144801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHI BLACK

Provider Business Mailing Address
First Line	:	11201 MIST MOOR CT
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-6314
Country	:	US
Telephone Number	:	813-577-4437
Fax Number	:

Provider Business Practice Location Address
First Line	:	2406 W BRANDON BLVD
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-4717
Country	:	US
Telephone Number	:	813-654-0686
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	07/08/2007

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Directions to “ KATHI BLACK ” Practice Location

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