Provider Demographics
NPI:1679936744
Name:BLACK, SELENE (CCC-SLP, MS)
Entity type:Individual
Prefix:MRS
First Name:SELENE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:CCC-SLP, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7784 INNOVATION PARK DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70820-7006
Mailing Address - Country:US
Mailing Address - Phone:225-343-4232
Mailing Address - Fax:225-343-4233
Practice Address - Street 1:7784 INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70820-7006
Practice Address - Country:US
Practice Address - Phone:225-343-4232
Practice Address - Fax:225-343-4233
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6442235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist