MEDICARE: SUSAN H 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
1	1041C0700X	Clinical Social Worker	I. 0004879	OH

General Provider Information

NPI Number	:	1871513945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN H BLACK LISW

Provider Business Mailing Address
First Line	:	5700 DRAKE RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45243-3619
Country	:	US
Telephone Number	:	513-891-6040
Fax Number	:	513-891-2580

Provider Business Practice Location Address
First Line	:	9200 MONTGOMERY RD
Second Line	:	SUITE C 11 A
City	:	CINCINNATI
State	:	OH
Zip	:	45242-7789
Country	:	US
Telephone Number	:	513-891-6040
Fax Number	:	513-891-2580

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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