Provider Demographics
NPI:1669533782
Name:BLACK, LORI ANN (PT)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 VILLAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862
Mailing Address - Country:US
Mailing Address - Phone:865-908-3261
Mailing Address - Fax:865-908-7043
Practice Address - Street 1:407 4TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3755
Practice Address - Country:US
Practice Address - Phone:423-625-8446
Practice Address - Fax:423-623-1899
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3653247Medicare ID - Type Unspecified