Basic Information
| Provider Information | |||||||||
| NPI: | 1497378947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | GEORGIA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE # MS 958 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142667615 | ||||||||
| FaxNumber: | 4142666238 | ||||||||
| Practice Location | |||||||||
| Address1: | 4855 S MOORLAND RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531517495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2624327702 | ||||||||
| FaxNumber: | 2624327795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2020 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 221700000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist | 101YP2500X | 4665 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1497378947 | 05 | WI | MEDICAID |