Provider Demographics
NPI:1851761365
Name:GRASS BLACK, CYNTHIA CATHERINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:CATHERINE
Last Name:GRASS BLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CINDY
Other - Middle Name:CATHERINE
Other - Last Name:GRASS BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, BCD
Mailing Address - Street 1:8592 BELL LANE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307
Mailing Address - Country:US
Mailing Address - Phone:219-775-7529
Mailing Address - Fax:219-937-3012
Practice Address - Street 1:8592 BELL LANE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307
Practice Address - Country:US
Practice Address - Phone:219-775-7529
Practice Address - Fax:219-937-3012
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003234A1041C0700X
IL149.0043311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical