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NPI Code Detail

MEDICARE: RUSTY BLACK

MEDICARE: RUSTY 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
1101YM0800XMental Health Counselor27272FL

General Provider Information

NPI Number : 1871432690
Entity Type Code : Individual
Provider Name (Legal Business Name) : RUSTY BLACK
Provider Business Mailing Address
First Line : 350 PENSACOLA BEACH RD
Second Line :
City : GULF BREEZE
State : FL
Zip : 32561-4815
Country : US
Telephone Number : 833-551-2304
Fax Number :
Provider Business Practice Location Address
First Line : 350 PENSACOLA BEACH RD
Second Line :
City : GULF BREEZE
State : FL
Zip : 32561-4815
Country : US
Telephone Number : 833-551-2304
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/26/2026
Last Update Date : 03/26/2026

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Directions to “ RUSTY BLACK ” Practice Location

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