Provider Demographics
NPI:1073814828
Name:BLACK, CHRISTINE MARIE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 COLLINS DR
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-2346
Mailing Address - Country:US
Mailing Address - Phone:636-931-4206
Mailing Address - Fax:636-931-5774
Practice Address - Street 1:1 KWAN PLZ
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1435
Practice Address - Country:US
Practice Address - Phone:573-438-0751
Practice Address - Fax:573-438-5460
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080096191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2008009619OtherSTATE LICENSE