Healthcare Provider Details

I. General information

NPI: 1396003414
Provider Name (Legal Business Name): RYAN RUSSELL BLACK LMSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 03/03/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL OPC 371 BOX 39
APO AP
96271-9001
US

IV. Provider business mailing address

BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL OPC 371 BOX 39
APO AP
96271
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-3711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC008913
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: