Provider Demographics
NPI:1033701289
Name:FLACK, COURTNEY NICOLE (LCSWA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:FLACK
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:BARIUM SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28010-0001
Mailing Address - Country:US
Mailing Address - Phone:704-832-2200
Mailing Address - Fax:704-838-1541
Practice Address - Street 1:5700 EXECUTIVE CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8833
Practice Address - Country:US
Practice Address - Phone:800-320-4157
Practice Address - Fax:704-494-7796
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0154591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP015459OtherLICENSE