Individual
DERONDA ANN BLACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OTR
Contact information
Practice address
14416 PORTAGE RD, VICKSBURG, MI 49097-9732
(269) 649-1848
(269) 649-1848
Mailing address
PO BOX 202, VICKSBURG, MI 49097-0202
(269) 649-1848
(269) 649-1848
Taxonomy
Speciality
Code
Description
License number
State
225XP0200X
Pediatric Occupational Therapist
Primary
31004281A
IN
Other
Enumeration date
05/12/2008
Last updated
05/12/2008
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