Provider Demographics
NPI:1003246810
Name:BLACK, VANESSA (MAED, CSOTP, LPC NCC)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MAED, CSOTP, LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18201 SNEADS GROVE RD
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-3061
Mailing Address - Country:US
Mailing Address - Phone:910-384-2175
Mailing Address - Fax:877-898-2026
Practice Address - Street 1:1000 S MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-4764
Practice Address - Country:US
Practice Address - Phone:910-384-2175
Practice Address - Fax:877-898-2026
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional