Provider Demographics
NPI:1912356361
Name:BLACK, KALYN (LISW)
Entity Type:Individual
Prefix:MS
First Name:KALYN
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVENUE
Mailing Address - Street 2:MLC 3014
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4788
Mailing Address - Fax:513-517-0860
Practice Address - Street 1:3333 BURNET AVENUE
Practice Address - Street 2:MLC 3014
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4788
Practice Address - Fax:513-517-0860
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1502337104100000X
OHI.19018141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker