Provider Demographics
NPI:1841366721
Name:BLACK, CONSTANCE ANN (DC)
Entity type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6044 N LANDERS
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5614
Mailing Address - Country:US
Mailing Address - Phone:773-774-8278
Mailing Address - Fax:
Practice Address - Street 1:1609 SHERMAN AVE
Practice Address - Street 2:STE 204
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3753
Practice Address - Country:US
Practice Address - Phone:847-328-2008
Practice Address - Fax:847-328-8171
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01682433OtherBCBS
IL612940Medicare ID - Type Unspecified