Provider Demographics
NPI:1629532304
Name:BLACK, MONICA FLEETWOOD (LCSW, MSW, MA)
Entity Type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:FLEETWOOD
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW, MSW, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 E THORNTON DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6664
Mailing Address - Country:US
Mailing Address - Phone:812-322-7583
Mailing Address - Fax:
Practice Address - Street 1:350 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5001
Practice Address - Country:US
Practice Address - Phone:812-676-4540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007844A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical