Provider Demographics
NPI:1730857616
Name:BLACK, MORGAN HANSEN (DPT)
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:HANSEN
Last Name:BLACK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 N 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025-2444
Mailing Address - Country:US
Mailing Address - Phone:801-850-7987
Mailing Address - Fax:
Practice Address - Street 1:121 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:AZ
Practice Address - Zip Code:85929
Practice Address - Country:US
Practice Address - Phone:928-536-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-31966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist