Provider Demographics
NPI:1033916887
Name:BLACK, EMMA (MS, RDN)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:CO
Mailing Address - Zip Code:80540-8131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 DELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3125
Practice Address - Country:US
Practice Address - Phone:843-822-8040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-28
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered