Provider Demographics
NPI:1003110198
Name:BLACK, JUDITH ANN (PHD, LPC, LCMHC, NCC)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD, LPC, LCMHC, NCC
Other - Prefix:DR
Other - First Name:JUDE
Other - Middle Name:A
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:12 WOODCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1257
Mailing Address - Country:US
Mailing Address - Phone:910-689-7100
Mailing Address - Fax:
Practice Address - Street 1:207 FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2710
Practice Address - Country:US
Practice Address - Phone:681-404-6869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA8388101YP2500X
VA0701005401101YP2500X
NC275728101YP2500X
NC8388101YP2500X
WV2278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWVTPID009357Medicaid