Provider Demographics
NPI:1861585978
Name:BLACK, AUSTIN C (AUD)
Entity type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:C
Last Name:BLACK
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 S FERDON BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5481
Mailing Address - Country:US
Mailing Address - Phone:850-683-8777
Mailing Address - Fax:
Practice Address - Street 1:2670 S FERDON BLVD STE 105
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5481
Practice Address - Country:US
Practice Address - Phone:850-683-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0388231HA2400X, 231HA2500X, 237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP01323Medicare UPIN
KY0996001Medicare ID - Type Unspecified