Healthcare Provider Details

I. General information

NPI: 1811568025
Provider Name (Legal Business Name): SAMANTHA BLACK PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2238 S HAMILTON RD STE 200
COLUMBUS OH
43232-4382
US

IV. Provider business mailing address

106 STARRET ST STE 100
LANCASTER OH
43130-3993
US

V. Phone/Fax

Practice location:
  • Phone: 740-751-0042
  • Fax:
Mailing address:
  • Phone: 740-687-0042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number08687
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: