Provider Demographics
NPI:1225330277
Name:BLACK, JOHN ALAN (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALAN
Last Name:BLACK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 OAK AVE APT 410W
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-7400
Mailing Address - Country:US
Mailing Address - Phone:702-334-9755
Mailing Address - Fax:
Practice Address - Street 1:8401 CRAWFORD AVE STE 106
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-2154
Practice Address - Country:US
Practice Address - Phone:847-423-2625
Practice Address - Fax:847-737-1663
Is Sole Proprietor?:No
Enumeration Date:2010-11-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK41351041C0700X
TX560851041C0700X
IL149.0196441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical