Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT1649 | MS |
NPI | 1003081993 |
---|---|
Provider Name | Mrs. Marzelle Claassen Black |
First Address | Ridgeland, MS 39157-5120 |
Second Address | Woodland Park, CO 80863-8760 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/04/2008 |
Last Update Date | 27/03/2020 |