Individual
TINA MARIE BLACK
Active
Individual
TINA MARIE BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Taxonomy
Speciality
Code
Description
License number
State
225XP0200X
Pediatric Occupational Therapist
Primary
OT003199
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10038361
AMERIGROUP
GA
01
—
307327
WELLCARE
GA
Enumeration date
11/09/2006
Last updated
07/09/2007
Update your record
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