Provider Demographics
NPI:1104667583
Name:BLACK, CARRIE L
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:884 MISSION RD SW
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-7411
Mailing Address - Country:US
Mailing Address - Phone:678-431-2390
Mailing Address - Fax:
Practice Address - Street 1:200 LEAKE ST STE 106
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3562
Practice Address - Country:US
Practice Address - Phone:678-431-2390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-01
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor