Provider Demographics
NPI:1124178918
Name:BLACK, JOSEPH EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:EDWARD
Last Name:BLACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:J.
Other - Middle Name:EDWARD
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1328 CREMEENS RD
Mailing Address - Street 2:
Mailing Address - City:PATRIOT
Mailing Address - State:OH
Mailing Address - Zip Code:45658-9319
Mailing Address - Country:US
Mailing Address - Phone:740-256-6442
Mailing Address - Fax:
Practice Address - Street 1:731 E MAIN ST
Practice Address - Street 2:SUITE 13
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-2100
Practice Address - Country:US
Practice Address - Phone:740-286-8789
Practice Address - Fax:740-286-8789
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4889103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2047529Medicaid
OHBLCP19435Medicare ID - Type Unspecified
OH2047529Medicaid