Provider Demographics
NPI:1881568210
Name:BLACK, DIAMOND MARIE
Entity type:Individual
Prefix:
First Name:DIAMOND
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18605 KEWANEE AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44119-2736
Mailing Address - Country:US
Mailing Address - Phone:440-596-0655
Mailing Address - Fax:
Practice Address - Street 1:18605 KEWANEE AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44119-2736
Practice Address - Country:US
Practice Address - Phone:440-596-0655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-30
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities