Provider Demographics
NPI:1245748722
Name:BLACKBIRD BEHAVIORAL HEALTH, PC
Entity Type:Organization
Organization Name:BLACKBIRD BEHAVIORAL HEALTH, PC
Other - Org Name:BLACKBIRD BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:K
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:708-209-8987
Mailing Address - Street 1:633 CARPENTER AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1104
Mailing Address - Country:US
Mailing Address - Phone:708-209-8987
Mailing Address - Fax:
Practice Address - Street 1:715 LAKE ST STE 410
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1413
Practice Address - Country:US
Practice Address - Phone:708-209-8987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-18
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)