1851761365 NPI number — MS. CYNTHIA CATHERINE GRASS BLACK L.C.S.W.

Table of content: MS. CYNTHIA CATHERINE GRASS BLACK L.C.S.W. (NPI 1851761365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851761365 NPI number — MS. CYNTHIA CATHERINE GRASS BLACK L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRASS BLACK
Provider First Name:
CYNTHIA
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRASS BLACK
Provider Other First Name:
CINDY
Provider Other Middle Name:
CATHERINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.C.S.W., B.C.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1851761365
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8592 BELL LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROWN POINT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-775-7529
Provider Business Mailing Address Fax Number:
219-937-3012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8592 BELL LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-775-7529
Provider Business Practice Location Address Fax Number:
219-937-3012
Provider Enumeration Date:
09/28/2015

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:  34003234A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 149.004331 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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