Provider Demographics
NPI:1700202033
Name:BLACK, HEIDI KRISTINA (LSW)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:KRISTINA
Last Name:BLACK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 STOW AVE
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-2521
Mailing Address - Country:US
Mailing Address - Phone:330-926-3800
Mailing Address - Fax:330-920-1074
Practice Address - Street 1:431 STOW AVE
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-2521
Practice Address - Country:US
Practice Address - Phone:330-926-3800
Practice Address - Fax:330-920-1074
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0027921104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker