Provider Demographics
NPI:1003107731
Name:BLACK, LEAH (LCSW)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:
Other - Last Name:HURST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 13572
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-3572
Mailing Address - Country:US
Mailing Address - Phone:307-654-7003
Mailing Address - Fax:307-224-4973
Practice Address - Street 1:310 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8636
Practice Address - Country:US
Practice Address - Phone:307-654-7003
Practice Address - Fax:307-224-4973
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-7421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117699400Medicaid