Misty Renae Black, PTA

Primary specialty

Physical Therapy AssistantTaxonomy code 225200000X

License

AT6901 Issued in CA

Practice address

100 Pleasant Hill Ave N
Sebastopol, CA 95472-3104

Phone

(707) 829-3282

Fax

(707) 829-3287

NPI assigned

Nov 28, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Sebastopol Physical Therapy and Pilates Studio

  • Physical Therapist
  • Sebastopol, CA
  • NPI 1538201546
  NPD (past)
• Stithem & Johnson Physical Therapy Inc.

  • Physical Therapy Clinic/Center
  • Santa Rosa, CA
  • NPI 1831386838

  Physical Therapist

  NPD (past)
• Stithem & Johnson Physical Therapy, Inc.

  • Physical Therapy Clinic/Center
  • Santa Rosa, CA
  • NPI 1982689675

  Physical Therapist

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164672000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1646092800000",
    "number": "1043386220",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 PLEASANT HILL AVE N",
            "city": "SEBASTOPOL",
            "state": "CA",
            "postal_code": "954723104",
            "telephone_number": "707-829-3282",
            "fax_number": "707-829-3287"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 PLEASANT HILL AVE N",
            "city": "SEBASTOPOL",
            "state": "CA",
            "postal_code": "954723104",
            "telephone_number": "707-829-3282",
            "fax_number": "707-829-3287"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLACK",
        "first_name": "MISTY",
        "middle_name": "RENAE",
        "credential": "PTA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-11-28",
        "last_updated": "2022-03-01",
        "certification_date": "2022-03-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "CA",
            "license": "AT6901",
            "primary": true
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "CA",
            "license": "AT6901",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Scott Benstock, DDS
• Karen H Bergman, LCSW
• Rhonda Berney, M.D.
• Allan L. Bernstein, MD
• Daniel Bierman, JD, MA
• John Thomas Blount, D.D.S.
• Gretchen Linda Carol Blum
• Karin N Boehm, O.D.
• Bohemian Concierge Care
• Jerry Michael Bolduan, MD

• Physical Therapy Assistant in Sebastopol, CA
• Providers in Sebastopol, CA by specialty
• Physical Therapy Assistant in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 1, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.