Provider Demographics
NPI:1780371310
Name:BLACK, JULIE CHRISTINE
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:CHRISTINE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 ARNDALE RD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-2307
Mailing Address - Country:US
Mailing Address - Phone:850-532-5694
Mailing Address - Fax:
Practice Address - Street 1:2680 W MARKET ST
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-4215
Practice Address - Country:US
Practice Address - Phone:234-867-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2304738-TRNE101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional