Healthcare Provider Details

I. General information

NPI: 1942336672
Provider Name (Legal Business Name): AMY LOUISE BLACK DT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6448 N OAK PARK AVE 2N
CHICAGO IL
60631-2018
US

IV. Provider business mailing address

6448 N OAK PARK AVE 2N
CHICAGO IL
60631-2018
US

V. Phone/Fax

Practice location:
  • Phone: 847-347-6283
  • Fax:
Mailing address:
  • Phone: 847-347-6283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberAB46220100P
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: