Provider Demographics
NPI:1568430528
Name:BLACK, SUSAN L (MSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
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 1:5007 EDENVALE CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3189
Mailing Address - Country:US
Mailing Address - Phone:202-404-4242
Mailing Address - Fax:202-404-7366
Practice Address - Street 1:238 BROOKLEY AVE
Practice Address - Street 2:11TH MEDICAL GROUP/SGOH
Practice Address - City:BOLLING AFB
Practice Address - State:DC
Practice Address - Zip Code:20032
Practice Address - Country:US
Practice Address - Phone:202-404-4242
Practice Address - Fax:202-404-7366
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC53641041C0700X
FL63831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical