Provider Demographics
NPI:1730111378
Name:BLACK, CHARLES JOSEPH (LISW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:BLACK
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5893 THORNY RDG
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-5804
Mailing Address - Country:US
Mailing Address - Phone:513-831-1305
Mailing Address - Fax:
Practice Address - Street 1:4355 FERGUSON DR
Practice Address - Street 2:SUITE 270
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-5136
Practice Address - Country:US
Practice Address - Phone:513-943-3680
Practice Address - Fax:513-943-3699
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-48201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical