Provider Demographics
NPI:1720774011
Name:BLACK, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8731 N 64TH ST
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-2823
Mailing Address - Country:US
Mailing Address - Phone:414-367-7176
Mailing Address - Fax:
Practice Address - Street 1:8731 N 64TH ST
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-2823
Practice Address - Country:US
Practice Address - Phone:414-367-7176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator