Provider Demographics
NPI:1306477054
Name:BLACK, FELICIA R (LCSW)
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 MEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13208-1941
Mailing Address - Country:US
Mailing Address - Phone:315-491-5001
Mailing Address - Fax:
Practice Address - Street 1:7521 MORGAN RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3538
Practice Address - Country:US
Practice Address - Phone:315-677-7330
Practice Address - Fax:315-677-7331
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
NY0962801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker