Provider Demographics
NPI:1821049412
Name:BLACK, SIONAG M (PHD)
Entity Type:Individual
Prefix:MS
First Name:SIONAG
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 FRONT STREET
Mailing Address - Street 2:SUITE 3D
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916
Mailing Address - Country:US
Mailing Address - Phone:920-885-2780
Mailing Address - Fax:920-885-2788
Practice Address - Street 1:200 FRONT STREET
Practice Address - Street 2:SUITE 3D
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916
Practice Address - Country:US
Practice Address - Phone:920-885-2780
Practice Address - Fax:920-885-2788
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1012057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39077100Medicaid
WI39077100Medicaid