Healthcare Provider Details

I. General information

NPI: 1073814828
Provider Name (Legal Business Name): CHRISTINE MARIE BLACK MSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KWAN PLZ
POTOSI MO
63664-1435
US

IV. Provider business mailing address

3309 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63139-1101
US

V. Phone/Fax

Practice location:
  • Phone: 573-438-0751
  • Fax: 573-438-5460
Mailing address:
  • Phone: 314-206-3700
  • Fax: 314-206-3708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2008009619
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: