Provider Demographics
NPI:1477225266
Name:BLACK, TAMARA (LCSW-R)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 QUENTIN RD STE 110
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4245
Mailing Address - Country:US
Mailing Address - Phone:800-275-3243
Mailing Address - Fax:
Practice Address - Street 1:3512 QUENTIN RD STE 110
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4245
Practice Address - Country:US
Practice Address - Phone:800-275-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0582431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical