Provider Demographics
NPI:1598006348
Name:BLACK, DORIS DANELLE (LSW)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:DANELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:DORIS
Other - Middle Name:DANELLE
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4670
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43058-4670
Mailing Address - Country:US
Mailing Address - Phone:740-788-0265
Mailing Address - Fax:740-788-3424
Practice Address - Street 1:8402 BLACKJACK ROAD EXT
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9193
Practice Address - Country:US
Practice Address - Phone:740-522-8477
Practice Address - Fax:740-788-3424
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1201160104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker