Provider Demographics
NPI:1366972069
Name:BLACK, MORGAN CELESTE
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:CELESTE
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 1:612 WOODLAND SQUARE LOOP SE STE 401
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1070
Mailing Address - Country:US
Mailing Address - Phone:360-999-9053
Mailing Address - Fax:
Practice Address - Street 1:612 WOODLAND SQUARE LOOP SE STE 401
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98503
Practice Address - Country:US
Practice Address - Phone:360-999-9053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60190853101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1366972069Medicaid