Provider Demographics
NPI:1649762782
Name:BLACK, PAMELA M
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 WAUBONSEE DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:IL
Mailing Address - Zip Code:60545-2264
Mailing Address - Country:US
Mailing Address - Phone:331-999-8589
Mailing Address - Fax:
Practice Address - Street 1:1630 PLUM ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3462
Practice Address - Country:US
Practice Address - Phone:630-892-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health