Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1750673216 |
---|---|
Provider Name | Mrs. Tiffany Clevette Black |
First Address | Spencer, OK 73084-3258 |
Second Address | Spencer, OK 73084-3258 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2011 |
Last Update Date | 03/05/2011 |