Provider Demographics
NPI:1144889650
Name:BLACK, JOEL M (LCSW)
Entity type:Individual
Prefix:MR
First Name:JOEL
Middle Name:M
Last Name:BLACK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:1235 CLIFFRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:VALLEY PARK
Mailing Address - State:MO
Mailing Address - Zip Code:63088-1174
Mailing Address - Country:US
Mailing Address - Phone:618-741-4985
Mailing Address - Fax:
Practice Address - Street 1:8045 BIG BEND BLVD STE 101&109
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2709
Practice Address - Country:US
Practice Address - Phone:314-800-0311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-08
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170025711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490074023Medicaid