Provider Demographics
NPI:1174908099
Name:BLACK, JOHANNA CATHERINE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:CATHERINE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:CO
Mailing Address - Zip Code:80540-0725
Mailing Address - Country:US
Mailing Address - Phone:617-971-7844
Mailing Address - Fax:
Practice Address - Street 1:1501 YARMOUTH AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-0564
Practice Address - Country:US
Practice Address - Phone:413-570-0534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLSW.0009920730101YM0800X
COCSW.099243111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health