MEDICARE: MRS. AUDREY EVERETT BLACK M.S., CCC-SLP

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	235Z00000X	Speech-Language Pathologist	101106	TX

General Provider Information

NPI Number	:	1245968155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AUDREY EVERETT BLACK M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	1200 W 2ND ST
Second Line	:
City	:	FORT STOCKTON
State	:	TX
Zip	:	79735-6432
Country	:	US
Telephone Number	:	806-778-8326
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 W 2ND ST
Second Line	:
City	:	FORT STOCKTON
State	:	TX
Zip	:	79735-6432
Country	:	US
Telephone Number	:	806-778-8326
Fax Number	:

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

Provider Enumeration Date	:	08/09/2022
Last Update Date	:	08/09/2022

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Directions to “ MRS. AUDREY EVERETT BLACK M.S., CCC-SLP” Practice Location

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