Provider Demographics
NPI:1942336672
Name:BLACK, AMY LOUISE (DT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LOUISE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6448 N OAK PARK AVE
Mailing Address - Street 2:2N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-2018
Mailing Address - Country:US
Mailing Address - Phone:847-347-6283
Mailing Address - Fax:
Practice Address - Street 1:6448 N OAK PARK AVE
Practice Address - Street 2:2N
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-2018
Practice Address - Country:US
Practice Address - Phone:847-347-6283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAB46220100P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist