Provider Demographics
NPI:1467750497
Name:BLACK, MEGAN (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:415 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1230
Mailing Address - Country:US
Mailing Address - Phone:812-423-7791
Mailing Address - Fax:812-422-7558
Practice Address - Street 1:100 VISTA DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IN
Practice Address - Zip Code:47620-1266
Practice Address - Country:US
Practice Address - Phone:812-838-6558
Practice Address - Fax:812-422-7558
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006964A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100240880Medicaid
IN000000871089OtherANTHEM
12688390OtherCAQH
IN839090008OtherMEDICARE