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General NPI Number Information
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NPI Number | 1952066441
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Entity Type | Individual
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Provider Name | AMY KRISTIN BLACK LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/01/2021
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Last Update Date | 11/01/2021
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Provider Practice Location Address
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Address Line | 5000 S 5TH AVE
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City | HINES
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State | IL
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Zip | 60141-3030
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Country | US
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Telephone | 708-202-7816
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Fax |
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Provider Business Mailing Address
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Address Line | 3342 N OAKLEY AVE APT 3N
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City | CHICAGO
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State | IL
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Zip | 60618-6235
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Country | US
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Telephone | 312-231-8593
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.022647
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License Number State | IL
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