Sionag M Black, PHD
Individual provider Active NPI Clinical Psychologist · Beaver Dam, WI
NPI 1821049412 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1821049412
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Clinical Psychologist 103TC0700X
- License
- 1012057 (WI)
- Practice address
- 200 Front Street
Suite 3D
Beaver Dam, WI 53916 - Phone
- (920) 885-2780
- Fax
- (920) 885-2788
- NPI assigned
- May 16, 2006
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1012057 | WI | MD | Clinical Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Agnesian Healthcare | Past | Accepting new patients | |
| Agnesian Healthcare Inc | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 1012057 | WI | Yes |
Addresses
Primary practice location
200 Front Street
Suite 3D
Beaver Dam, WI 53916
Mailing address
200 Front Street
Suite 3D
Beaver Dam, WI 53916
Phone (920) 885-2780
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 39077100 | Medicaid | WI |
Other providers in Beaver Dam, WI
- Eric Berger
- Marie A Berry
- Adam Charles Biddle
- Chloe Bille
- Ronay Bjerke
- Jessica Marie Blatz
- Andrea Michelle Bluel
- Asiedu Boateng
- Kristin Bonilla
- Scott Robert Borkenhagen
All providers in Beaver Dam, WI · Clinical Psychologist in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.