Provider Demographics
NPI:1437260692
Name:BLACK, RUTH THERESA (LCSW-R)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:THERESA
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:THERESA
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:29 TENNYSON AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216
Mailing Address - Country:US
Mailing Address - Phone:716-876-8126
Mailing Address - Fax:716-876-8126
Practice Address - Street 1:29 TENNYSON AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14216
Practice Address - Country:US
Practice Address - Phone:716-876-8126
Practice Address - Fax:716-876-8126
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR024068-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7400103OtherEMPIRE
110342OtherVALUE OPTIONS
030194OtherGHI
00510617003OtherBCBS
00510617003OtherBCBS