Provider Demographics
NPI:1033867437
Name:BLACK, KERRI (LCDCII)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:833-510-4357
Mailing Address - Fax:
Practice Address - Street 1:126 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2593
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH174140101YA0400X
OHLCDCII.161824101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH174140Medicaid