Provider Demographics
NPI:1023368941
Name:BLACK CHILDERS, ANGELA R (LCSW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:R
Last Name:BLACK CHILDERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 WARNER ST
Mailing Address - Street 2:
Mailing Address - City:HAMPSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-9461
Mailing Address - Country:US
Mailing Address - Phone:815-600-1999
Mailing Address - Fax:
Practice Address - Street 1:600 SPRING HILL RING RD
Practice Address - Street 2:SUITE 113 A
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-7300
Practice Address - Country:US
Practice Address - Phone:815-600-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490076681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical