Provider Demographics
NPI:1700652948
Name:BLACK, CONNER JAMES (PHD)
Entity type:Individual
Prefix:
First Name:CONNER
Middle Name:JAMES
Last Name:BLACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BLOOMINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-5061
Practice Address - Country:US
Practice Address - Phone:401-432-1000
Practice Address - Fax:401-432-1500
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
RIPS02300103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist