Provider Demographics
NPI:1114018488
Name:BLACK, MARCIA GAIL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:GAIL
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 RESEARCH DR STE 1A
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-2775
Mailing Address - Country:US
Mailing Address - Phone:413-687-7559
Mailing Address - Fax:413-687-7559
Practice Address - Street 1:9 RESEARCH DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-2774
Practice Address - Country:US
Practice Address - Phone:413-687-7559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA6786PSYCH103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000533266OtherAETNA
8635OtherUBH
MA028140OtherBOSTON MED CENTER HEALTH
MA1853601Medicaid
357374OtherTUFTS
MAW05381Medicare ID - Type UnspecifiedIBLCR