Provider Demographics
NPI:1588426803
Name:BLACK, KATIE LINN KELLY (LPC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LINN KELLY
Last Name:BLACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 ASHPORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-7327
Mailing Address - Country:US
Mailing Address - Phone:731-431-5069
Mailing Address - Fax:
Practice Address - Street 1:650 ASHPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-7327
Practice Address - Country:US
Practice Address - Phone:731-431-5069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6968101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional