MEDICARE: MS. AMY LOUISE BLACK DT

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	222Q00000X	Developmental Therapist	AB46220100P	IL

General Provider Information

NPI Number	:	1942336672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMY LOUISE BLACK DT

Provider Business Mailing Address
First Line	:	6448 N OAK PARK AVE
Second Line	:	2N
City	:	CHICAGO
State	:	IL
Zip	:	60631-2018
Country	:	US
Telephone Number	:	847-347-6283
Fax Number	:

Provider Business Practice Location Address
First Line	:	6448 N OAK PARK AVE
Second Line	:	2N
City	:	CHICAGO
State	:	IL
Zip	:	60631-2018
Country	:	US
Telephone Number	:	847-347-6283
Fax Number	:

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	09/25/2015

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