Healthcare Provider Details

I. General information

NPI: 1568694248
Provider Name (Legal Business Name): THERESA JOY BLACK LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E COLLEGE AVE
WESTERVILLE OH
43081-1658
US

IV. Provider business mailing address

107 E COLLEGE AVE
WESTERVILLE OH
43081-1658
US

V. Phone/Fax

Practice location:
  • Phone: 614-733-4421
  • Fax:
Mailing address:
  • Phone: 614-733-4421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0600045
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: