Basic Information
| Provider Information | |||||||||
| NPI: | 1184818601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT, EDD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LATTANZI | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | BLACK | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 701 SAVANNAH RD | ||||||||
| Address2: | A-1 | ||||||||
| City: | LEWES | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199581550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026442530 | ||||||||
| FaxNumber: | 3026442556 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 SAVANNAH RD | ||||||||
| Address2: | A-1 | ||||||||
| City: | LEWES | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199581550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026442530 | ||||||||
| FaxNumber: | 3026442556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2007 | ||||||||
| LastUpdateDate: | 07/03/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J10000513 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1184818601 | 05 | DE | MEDICAID |