Provider Demographics
NPI:1467148825
Name:BLACK, RACHEL MICHELLE (BCBA)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:MICHELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-6610
Mailing Address - Country:US
Mailing Address - Phone:317-610-1300
Mailing Address - Fax:
Practice Address - Street 1:2222 POSHARD DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-1843
Practice Address - Country:US
Practice Address - Phone:812-302-4750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-23-64995103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst