MEDICARE: MICHELLE LYNN JOCHIM BLACK PH.D.

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	103T00000X	Psychologist	2015035134	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2015035134	OTHER	MO	MEDICAL LICENSE
2	20042867A	OTHER	IN	MEDICAL LICENSE

General Provider Information

NPI Number	:	1356714893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE LYNN JOCHIM BLACK PH.D.

Provider Business Mailing Address
First Line	:	3800 PARK AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-2514
Country	:	US
Telephone Number	:	314-577-5667
Fax Number	:	314-268-2784

Provider Business Practice Location Address
First Line	:	3800 PARK AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-2514
Country	:	US
Telephone Number	:	314-577-5667
Fax Number	:	314-268-2784

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

Provider Enumeration Date	:	11/05/2015
Last Update Date	:	11/10/2020

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