Individual
TORI KYM BLACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
148 WARREN ST, LOWELL, MA 01852-2208
(978) 452-1736
Mailing address
236 BAY VIEW DR, SAN CARLOS, CA 94070-1644
(650) 906-0145
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
W258605720
AETNA
CA
Enumeration date
02/24/2020
Last updated
02/24/2020
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