Provider Demographics
NPI:1538294319
Name:BLACK, KATIE MARIE (MSW)
Entity Type:Individual
Prefix:MISS
First Name:KATIE
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12339 WOODROSE CT APT 4
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4634
Mailing Address - Country:US
Mailing Address - Phone:239-560-8239
Mailing Address - Fax:
Practice Address - Street 1:3900 BROADWAY STE B1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8193
Practice Address - Country:US
Practice Address - Phone:239-939-2808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW4475104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker