MEDICARE: LEAH BLACK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW-742	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003107731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH BLACK LCSW

Provider Business Mailing Address
First Line	:	PO BOX 13572
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83002-3572
Country	:	US
Telephone Number	:	307-654-7003
Fax Number	:	307-224-4973

Provider Business Practice Location Address
First Line	:	310 E BROADWAY AVE
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8636
Country	:	US
Telephone Number	:	307-654-7003
Fax Number	:	307-224-4973

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2011
Last Update Date	:	02/18/2015

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