Healthcare Provider Details

I. General information

NPI: 1700652948
Provider Name (Legal Business Name): CONNER JAMES BLACK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5061
US

IV. Provider business mailing address

21 BLOOMINGDALE RD
WHITE PLAINS NY
10605-1504
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-1000
  • Fax: 401-432-1500
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS02300
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: