Provider Demographics
NPI:1114088341
Name:BLACK, JAMES HENRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:HENRY
Last Name:BLACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N MIDVALE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3265
Mailing Address - Country:US
Mailing Address - Phone:609-852-8600
Mailing Address - Fax:608-238-1929
Practice Address - Street 1:310 N MIDVALE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3265
Practice Address - Country:US
Practice Address - Phone:609-852-8600
Practice Address - Fax:608-238-1929
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1620-057103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39255300Medicaid