Provider Demographics
NPI:1699061390
Name:BLACK, MICHAEL RICHARD (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
Last Name:BLACK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 N KOSTNER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-3532
Mailing Address - Country:US
Mailing Address - Phone:773-278-2643
Mailing Address - Fax:999-999-9999
Practice Address - Street 1:3139 N LINCOLN AVE STE 221
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3122
Practice Address - Country:US
Practice Address - Phone:773-458-0585
Practice Address - Fax:999-999-9999
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008134103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist