Provider Demographics
NPI:1679582548
Name:BLACK-POND, CONSTANCE A
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:A
Last Name:BLACK-POND
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 1:487 CHERRYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-373-6447
Mailing Address - Fax:269-373-1229
Practice Address - Street 1:4000 PORTAGE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-6900
Practice Address - Country:US
Practice Address - Phone:269-373-6447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001080101YM0800X
MI68010599661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical