Provider Demographics
NPI:1730353715
Name:BLACK, MARY K (MS, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:K
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 JACOBS MILL CT
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-8646
Mailing Address - Country:US
Mailing Address - Phone:803-419-0427
Mailing Address - Fax:
Practice Address - Street 1:16 JACOBS MILL CT
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-8646
Practice Address - Country:US
Practice Address - Phone:803-419-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC226225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist