Provider Demographics
NPI:1952066441
Name:BLACK, AMY KRISTIN (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KRISTIN
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3342 N OAKLEY AVE APT 3N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6235
Mailing Address - Country:US
Mailing Address - Phone:312-231-8593
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-7816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0226471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical