Provider Demographics
NPI:1184863474
Name:BLACK, OLA MARIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:OLA
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:OLA
Other - Middle Name:MARIE
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:7230 HERITAGE VILLAGE PLZ
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3053
Mailing Address - Country:US
Mailing Address - Phone:703-754-0636
Mailing Address - Fax:703-754-0646
Practice Address - Street 1:7230 HERITAGE VILLAGE PLZ
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3053
Practice Address - Country:US
Practice Address - Phone:703-754-0636
Practice Address - Fax:703-754-0646
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004158101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA20-2488611OtherEIN