Provider Demographics
NPI:1821506163
Name:BLACK, CHRISTOPHER G (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:G
Last Name:BLACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 DRIFTWOOD DR E APT 101
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-6069
Mailing Address - Country:US
Mailing Address - Phone:314-497-4844
Mailing Address - Fax:
Practice Address - Street 1:703 3RD ST RM 1120
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2081
Practice Address - Country:US
Practice Address - Phone:765-494-6995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043106A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling