Provider Demographics
NPI:1942966064
Name:BLACK, AUSTIN JOEL (PTA)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JOEL
Last Name:BLACK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 KNICKERBOCKER PL APT 1D
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-2186
Mailing Address - Country:US
Mailing Address - Phone:317-294-1584
Mailing Address - Fax:
Practice Address - Street 1:8140 TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5824
Practice Address - Country:US
Practice Address - Phone:317-875-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006408A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant