Provider Demographics
NPI:1043647605
Name:BLACK, GAIL R (LPC)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 MARILYN DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-0929
Mailing Address - Country:US
Mailing Address - Phone:573-469-5263
Mailing Address - Fax:
Practice Address - Street 1:2202 MARILYN DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-0929
Practice Address - Country:US
Practice Address - Phone:573-469-5263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013035383101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional