MEDICARE: BLACKBIRD BEHAVIORAL HEALTH, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1245748722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACKBIRD BEHAVIORAL HEALTH, PC

Provider Business Mailing Address
First Line	:	633 CARPENTER AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60304-1104
Country	:	US
Telephone Number	:	708-209-8987
Fax Number	:

Provider Business Practice Location Address
First Line	:	715 LAKE ST STE 410
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60301-1413
Country	:	US
Telephone Number	:	708-209-8987
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	SHARON K BLACK
Credential	:	PSY.D.
Telephone Number	:	708-209-8987

Provider Enumeration Date	:	01/18/2018
Last Update Date	:	03/26/2018

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