Provider Demographics
NPI:1871286922
Name:BLACK, DAISIREE LAUREN
Entity type:Individual
Prefix:
First Name:DAISIREE
Middle Name:LAUREN
Last Name:BLACK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1293 COPLEY RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-2766
Mailing Address - Country:US
Mailing Address - Phone:330-374-1199
Mailing Address - Fax:
Practice Address - Street 1:1293 COPLEY RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2766
Practice Address - Country:US
Practice Address - Phone:330-374-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOCPSA.161732405300000X
OHAPS.005184175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No175T00000XOther Service ProvidersPeer Specialist