Provider Demographics
NPI:1659679199
Name:BLACK, MICHAEL (LCSW, CACIII)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:LCSW, CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 S BROADWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-1582
Mailing Address - Country:US
Mailing Address - Phone:303-957-7567
Mailing Address - Fax:303-934-1262
Practice Address - Street 1:1212 S BROADWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-1582
Practice Address - Country:US
Practice Address - Phone:303-957-7567
Practice Address - Fax:303-934-1262
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC-7098101YA0400X
COCSW-12291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical