Provider Demographics
NPI:1851845267
Name:BLACK, SHARON (PHD, LP)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1774 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2730
Mailing Address - Country:US
Mailing Address - Phone:763-222-7362
Mailing Address - Fax:
Practice Address - Street 1:1774 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2730
Practice Address - Country:US
Practice Address - Phone:763-222-7362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program