Provider Demographics
NPI:1942925847
Name:BLACK, LORRAINE (BCD, CBE, PE, SBD)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:BCD, CBE, PE, SBD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N MILWAUKEE AVE # 1062
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1574
Mailing Address - Country:US
Mailing Address - Phone:708-522-7150
Mailing Address - Fax:
Practice Address - Street 1:1427 ACORN DR
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-1764
Practice Address - Country:US
Practice Address - Phone:708-522-7150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL88-1904965Medicaid