Provider Demographics
NPI:1912450305
Name:BLACK, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
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 1:4501 NW OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-1773
Mailing Address - Country:US
Mailing Address - Phone:917-952-0762
Mailing Address - Fax:
Practice Address - Street 1:1711 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660
Practice Address - Country:US
Practice Address - Phone:360-200-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical