Provider Demographics
NPI:1215435466
Name:BLACK, AVEEAVIS TERRYSEENA (LCDCIII , SWCA)
Entity type:Individual
Prefix:
First Name:AVEEAVIS
Middle Name:TERRYSEENA
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCDCIII , SWCA
Other - Prefix:MS
Other - First Name:AVEEAVISA
Other - Middle Name:TERRRYSEENA
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:815 SUNNYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1957
Mailing Address - Country:US
Mailing Address - Phone:937-238-5173
Mailing Address - Fax:
Practice Address - Street 1:815 SUNNYVIEW AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1957
Practice Address - Country:US
Practice Address - Phone:937-238-5173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH111922101YA0400X
OHW.00009771041C0700X
OHLCDCIII.021224101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical