Healthcare Provider Details

I. General information

NPI: 1114088341
Provider Name (Legal Business Name): JAMES HENRY BLACK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N MIDVALE BLVD SUITE 202
MADISON WI
53705-3265
US

IV. Provider business mailing address

310 N MIDVALE BLVD SUITE 202
MADISON WI
53705-3265
US

V. Phone/Fax

Practice location:
  • Phone: 609-852-8600
  • Fax: 608-238-1929
Mailing address:
  • Phone: 609-852-8600
  • Fax: 608-238-1929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1620-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: