Provider Demographics
NPI:1942449418
Name:BLACK, NANCY DUFFEY (MS, LICSW, CEAP, SAP)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:DUFFEY
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS, LICSW, CEAP, SAP
Other - Prefix:MS
Other - First Name:NANCY
Other - Middle Name:ANN
Other - Last Name:DUFFEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 BLACKBERRY LANE
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-2006
Mailing Address - Country:US
Mailing Address - Phone:763-443-3348
Mailing Address - Fax:888-244-9928
Practice Address - Street 1:2000 BLACKBERRY LANE
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-2006
Practice Address - Country:US
Practice Address - Phone:763-443-3348
Practice Address - Fax:888-244-9928
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN065101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1427293851Medicaid