Basic Information
| Provider Information | |||||||||
| NPI: | 1992137319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | LUCY | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STONE | ||||||||
| OtherFirstName: | LUCY | ||||||||
| OtherMiddleName: | MARY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 49 | ||||||||
| Address2: | |||||||||
| City: | HOOPER BAY | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996040049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077583500 | ||||||||
| FaxNumber: | 9077583540 | ||||||||
| Practice Location | |||||||||
| Address1: | AIRPORT ROAD | ||||||||
| Address2: | |||||||||
| City: | HOOPER BAY | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996040049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077583500 | ||||||||
| FaxNumber: | 9077583540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2013 | ||||||||
| LastUpdateDate: | 12/26/2013 | ||||||||
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| 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 | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1020986 | 05 | AK | MEDICAID |