Provider Demographics
NPI:1003306465
Name:BLACK, ADRIENNE NICOLE (RBT-17-45544)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:NICOLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:RBT-17-45544
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 WOODLAND DR
Mailing Address - Street 2:WOODLAND DR
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:779-423-7812
Mailing Address - Fax:
Practice Address - Street 1:519 WOODLAND DR
Practice Address - Street 2:WOODLAND DR
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:779-423-7812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-17-45544106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician