Provider Demographics
NPI:1669518478
Name:BLACK, JANICE A (MSW)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:A
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 OAK LN
Mailing Address - Street 2:
Mailing Address - City:EAST WATERBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04030-5119
Mailing Address - Country:US
Mailing Address - Phone:207-615-4125
Mailing Address - Fax:888-203-6496
Practice Address - Street 1:74 BEACH ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-2812
Practice Address - Country:US
Practice Address - Phone:207-284-3265
Practice Address - Fax:888-203-6496
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC11611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical