Provider Demographics
NPI:1164447819
Name:BLACK, ROSE M (MA REHAB COUNSELING)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA REHAB COUNSELING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 ST MATTHEWS RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118
Mailing Address - Country:US
Mailing Address - Phone:803-536-1571
Mailing Address - Fax:803-536-1463
Practice Address - Street 1:5573 CAROLINA HWY
Practice Address - Street 2:
Practice Address - City:DENMARK
Practice Address - State:SC
Practice Address - Zip Code:29042
Practice Address - Country:US
Practice Address - Phone:803-793-4274
Practice Address - Fax:803-793-4275
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC413093Medicaid
3345Medicare ID - Type Unspecified