Provider Demographics
NPI:1013568971
Name:BLACK, ADDISON
Entity Type:Individual
Prefix:
First Name:ADDISON
Middle Name:
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 1:814 TYVOLA RD STE 126
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-3539
Mailing Address - Country:US
Mailing Address - Phone:980-785-1113
Mailing Address - Fax:980-785-1114
Practice Address - Street 1:600 TOWNE CENTRE BLVD STE 403
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134-8475
Practice Address - Country:US
Practice Address - Phone:980-785-1113
Practice Address - Fax:980-785-1114
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-19-99326106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician