Individual
GEORGIA ROSE BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MS
Contact information
Practice address
4855 S MOORLAND RD STE 150, NEW BERLIN, WI 53151-7495
(262) 432-7702
(262) 432-7795
Mailing address
9000 W WISCONSIN AVE # MS 958, MILWAUKEE, WI 53226-4874
(414) 266-7615
(414) 266-6238
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
4665
WI
221700000X
Art Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1497378947
—
WI
Enumeration date
05/19/2020
Last updated
01/18/2022
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