1467750497 NPI number — MEGAN BLACK MSW, LCSW

Table of content: MEGAN BLACK MSW, LCSW (NPI 1467750497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467750497 NPI number — MEGAN BLACK MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
MEGAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLACK
Provider Other First Name:
MEGAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1467750497
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 MULBERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47713-1230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-423-7791
Provider Business Mailing Address Fax Number:
812-422-7558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 VISTA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47620-1266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-838-6558
Provider Business Practice Location Address Fax Number:
812-422-7558
Provider Enumeration Date:
02/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  34006964A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100240880 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000871089 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 12688390 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 839090008 . This is a "MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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