Provider Demographics
NPI:1447700802
Name:BLACK, CHELSIE R (PSYD, LP)
Entity type:Individual
Prefix:
First Name:CHELSIE
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:CHELSIE
Other - Middle Name:
Other - Last Name:HAINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:471-761-5000
Mailing Address - Fax:417-761-5011
Practice Address - Street 1:1300 E BRADFORD PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4264
Practice Address - Country:US
Practice Address - Phone:471-761-5000
Practice Address - Fax:417-761-5011
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016035949103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490036997Medicaid