Provider Demographics
NPI:1295981645
Name:BLACK, RODNEY (MSW)
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KALISA WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3508
Mailing Address - Country:US
Mailing Address - Phone:888-948-6789
Mailing Address - Fax:877-345-3501
Practice Address - Street 1:500 E LOCUST ST STE 126
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1955
Practice Address - Country:US
Practice Address - Phone:888-948-6789
Practice Address - Fax:877-345-3501
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01073104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker