=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871513945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN H BLACK LISW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9200 MONTGOMERY RD SUITE C 11 A
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-7789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-891-6040
-----------------------------------------------------
Fax | 513-891-2580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5700 DRAKE RD
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45243-3619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-891-6040
-----------------------------------------------------
Fax | 513-891-2580
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I. 0004879
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------