Provider Demographics
NPI:1992692198
Name:BLACK, KIRK L (MA, THERAPIST)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:L
Last Name:BLACK
Suffix:
Gender:M
Credentials:MA, THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 KITZMILLER RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-2202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:396 KITZMILLER RD
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-2202
Practice Address - Country:US
Practice Address - Phone:901-596-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health