Provider Demographics
NPI:1356714893
Name:BLACK, MICHELLE LYNN JOCHIM (PHD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN JOCHIM
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2514
Mailing Address - Country:US
Mailing Address - Phone:314-577-5667
Mailing Address - Fax:314-268-2784
Practice Address - Street 1:3800 PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2514
Practice Address - Country:US
Practice Address - Phone:314-577-5667
Practice Address - Fax:314-268-2784
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015035134103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015035134OtherMEDICAL LICENSE
IN20042867AOtherMEDICAL LICENSE