Healthcare Provider Details

I. General information

NPI: 1518305895
Provider Name (Legal Business Name): KALINA CRYSTAL BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WASHINGTON ST
BOSTON MA
02118-1951
US

IV. Provider business mailing address

9604 57TH AVE APT 11L
CORONA NY
11368-3418
US

V. Phone/Fax

Practice location:
  • Phone: 617-425-2000
  • Fax: 617-425-2002
Mailing address:
  • Phone: 646-956-0044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: