Provider Demographics
NPI:1023463106
Name:BLACK, CHELSEA (PHD)
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
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 1:3405 CIVIC CENTER BLVD RM 107
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4319
Mailing Address - Country:US
Mailing Address - Phone:215-590-7711
Mailing Address - Fax:
Practice Address - Street 1:3405 CIVIC CENTER BLVD RM 107
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
PAPS018498103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist