1013219930 NPI number — DR. NAOMI BLACK LPC

Table of content: DR. NAOMI BLACK LPC (NPI 1013219930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013219930 NPI number — DR. NAOMI BLACK LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
NAOMI
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013219930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
831 SYLVAN PL SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30310-4938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-556-8235
Provider Business Mailing Address Fax Number:
404-738-2932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 KENTUCKY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTDALE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30079-1124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-206-1262
Provider Business Practice Location Address Fax Number:
404-738-2932
Provider Enumeration Date:
11/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  APC-002554 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC-006344 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003234513A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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