Provider Demographics
NPI:1396184925
Name:BLACK, XENIA ZELDIN (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:XENIA
Middle Name:ZELDIN
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 NE RICE RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5849
Mailing Address - Country:US
Mailing Address - Phone:816-347-3069
Mailing Address - Fax:816-347-3200
Practice Address - Street 1:1535 NE RICE RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-5849
Practice Address - Country:US
Practice Address - Phone:816-966-0900
Practice Address - Fax:816-347-3209
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013018485323P00000X
MO20160084161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1396184925Medicaid