Provider Demographics
NPI:1902923071
Name:BLACK, KATHLEEN COLE (LBSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:COLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 MARLBOROUGH ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2950
Mailing Address - Country:US
Mailing Address - Phone:313-824-3230
Mailing Address - Fax:
Practice Address - Street 1:7737 KERCHEVAL ST
Practice Address - Street 2:ROOM 115
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-2437
Practice Address - Country:US
Practice Address - Phone:313-925-1135
Practice Address - Fax:313-925-2508
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1091543104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker