Provider Demographics
NPI:1760362073
Name:BLACK, KEISHA
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
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 1:6209 WINDSOR LN
Mailing Address - Street 2:
Mailing Address - City:PINSON
Mailing Address - State:AL
Mailing Address - Zip Code:35126-3490
Mailing Address - Country:US
Mailing Address - Phone:205-440-2294
Mailing Address - Fax:205-850-5571
Practice Address - Street 1:529 BEACON PKWY W STE 101
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-3126
Practice Address - Country:US
Practice Address - Phone:205-440-2294
Practice Address - Fax:205-850-5571
Is Sole Proprietor?:No
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5540235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist