Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 1620-057 | WI |
NPI | 1114088341 |
---|---|
Provider Name | Dr. James Henry Black |
First Address | Madison, WI 53705-3265 |
Second Address | Madison, WI 53705-3265 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2006 |
Last Update Date | 22/08/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
39255300 | (05) | WI |