Provider Demographics
NPI:1750756946
Name:BLACK, AMY SUE (MFT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4329 SOLUN RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46221-3030
Mailing Address - Country:US
Mailing Address - Phone:317-830-6276
Mailing Address - Fax:
Practice Address - Street 1:4329 SOLUN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-3030
Practice Address - Country:US
Practice Address - Phone:317-830-6276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist