Provider Demographics
NPI:1265743637
Name:BRENDA BLACK LCSW PC
Entity type:Organization
Organization Name:BRENDA BLACK LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:N
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW PC
Authorized Official - Phone:312-718-6996
Mailing Address - Street 1:717 MAIN ST
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1701
Mailing Address - Country:US
Mailing Address - Phone:312-718-6996
Mailing Address - Fax:
Practice Address - Street 1:717 MAIN ST
Practice Address - Street 2:SUITE 2E
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1701
Practice Address - Country:US
Practice Address - Phone:312-718-6996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490139291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty