MEDICARE: DIAMOND MARIE BLACK

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	103TM1800X	Intellectual & Developmental Disabilities Psychologist		OH

General Provider Information

NPI Number	:	1881568210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIAMOND MARIE BLACK

Provider Business Mailing Address
First Line	:	18605 KEWANEE AVE UNIT 1
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-2736
Country	:	US
Telephone Number	:	440-596-0655
Fax Number	:

Provider Business Practice Location Address
First Line	:	18605 KEWANEE AVE UNIT 1
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44119-2736
Country	:	US
Telephone Number	:	440-596-0655
Fax Number	:

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

Provider Enumeration Date	:	09/30/2025
Last Update Date	:	09/30/2025

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Directions to “ DIAMOND MARIE BLACK ” Practice Location

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