Provider Demographics
NPI:1669532107
Name:BLACK, MARY ELLEN (LISW LPCC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:BLACK
Suffix:
Gender:
Credentials:LISW LPCC
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW LPCC
Mailing Address - Street 1:102 EAST GAMBIER STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050
Mailing Address - Country:US
Mailing Address - Phone:740-392-5416
Mailing Address - Fax:740-392-3742
Practice Address - Street 1:102 EAST GAMBIER STREET
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050
Practice Address - Country:US
Practice Address - Phone:740-392-5416
Practice Address - Fax:740-392-3742
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0000717101YP2500X
OHI00007991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBLSW25441Medicare ID - Type Unspecified