Provider Demographics
NPI:1346397015
Name:BLACK, TERESE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:TERESE
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6774 N NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1275
Mailing Address - Country:US
Mailing Address - Phone:773-775-6510
Mailing Address - Fax:
Practice Address - Street 1:6774 N NORTHWEST HWY
Practice Address - Street 2:STE A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1275
Practice Address - Country:US
Practice Address - Phone:773-775-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2008-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010695111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor