MEDICARE: MRS. ROBYN L BLACK 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	41YS00536400	NJ

General Provider Information

NPI Number	:	1821243841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ROBYN L BLACK SLP

Provider Business Mailing Address
First Line	:	110 MONTGOMERY STREET
Second Line	:	APARTMENT 1R
City	:	HIGHLAND PARK
State	:	NJ
Zip	:	08904-2321
Country	:	US
Telephone Number	:	201-410-8902
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 MONTGOMERY ST
Second Line	:	APARTMENT 1R
City	:	HIGHLAND PARK
State	:	NJ
Zip	:	08904-2321
Country	:	US
Telephone Number	:	201-410-8902
Fax Number	:

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

Provider Enumeration Date	:	11/18/2008
Last Update Date	:	11/18/2008

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