Provider Demographics
NPI:1811306194
Name:BLACK, SHIMRIT KOREN (PHD)
Entity type:Individual
Prefix:DR
First Name:SHIMRIT
Middle Name:KOREN
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4817
Mailing Address - Country:US
Mailing Address - Phone:857-364-6612
Mailing Address - Fax:
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:857-364-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2015-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10059103TC0700X
10059103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral