Provider Demographics
NPI:1871513945
Name:BLACK, SUSAN H (LISW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:BLACK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45243-3619
Mailing Address - Country:US
Mailing Address - Phone:513-891-6040
Mailing Address - Fax:513-891-2580
Practice Address - Street 1:9200 MONTGOMERY RD
Practice Address - Street 2:SUITE C 11 A
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-7789
Practice Address - Country:US
Practice Address - Phone:513-891-6040
Practice Address - Fax:513-891-2580
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI. 00048791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical