Provider Demographics
NPI:1871984237
Name:BLACK, CAROLYN (MD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S COWLEY ST STE 228
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1383
Mailing Address - Country:US
Mailing Address - Phone:509-473-6706
Mailing Address - Fax:509-473-6704
Practice Address - Street 1:715 S COWLEY ST STE 228
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1383
Practice Address - Country:US
Practice Address - Phone:509-474-6706
Practice Address - Fax:509-473-6704
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA274832208100000X
WAMD61142658208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program