Provider Demographics
NPI:1093185068
Name:BLACK, BRENDA (LMSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 THURBER DR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 THURBER DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1665
Practice Address - Country:US
Practice Address - Phone:315-539-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0986261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical