Provider Demographics
NPI:1144813023
Name:BLACK, HEATHER C
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:C
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 TUB RUN HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:HEDGESVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25427-6674
Mailing Address - Country:US
Mailing Address - Phone:304-270-8424
Mailing Address - Fax:
Practice Address - Street 1:86 TUB RUN HOLLOW RD
Practice Address - Street 2:
Practice Address - City:HEDGESVILLE
Practice Address - State:WV
Practice Address - Zip Code:25427-6674
Practice Address - Country:US
Practice Address - Phone:304-270-8424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker