Provider Demographics
NPI:1184764698
Name:BLACK, NICHOLAS J (LMSW)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:J
Last Name:BLACK
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1395
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-1395
Mailing Address - Country:US
Mailing Address - Phone:505-832-4529
Mailing Address - Fax:
Practice Address - Street 1:350 MCNABB RD
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035
Practice Address - Country:US
Practice Address - Phone:505-638-5491
Practice Address - Fax:505-638-5571
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-047461041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM6281583Medicaid