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NPI Code Detail

MEDICARE: MR. CHARLES JOSEPH BLACK LISW

MEDICARE: MR. CHARLES JOSEPH BLACK LISW
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
11041C0700XClinical Social WorkerI-4820OH

General Provider Information

NPI Number : 1730111378
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. CHARLES JOSEPH BLACK LISW
Provider Business Mailing Address
First Line : 5893 THORNY RDG
Second Line :
City : MILFORD
State : OH
Zip : 45150-5804
Country : US
Telephone Number : 513-831-1305
Fax Number :
Provider Business Practice Location Address
First Line : 4355 FERGUSON DR
Second Line : SUITE 270
City : CINCINNATI
State : OH
Zip : 45245-5136
Country : US
Telephone Number : 513-943-3680
Fax Number : 513-943-3699
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/06/2006
Last Update Date : 07/08/2007

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