Provider Demographics
NPI:1326448960
Name:BLACK, SHAPHAUN TAMARA (CSAC)
Entity Type:Individual
Prefix:
First Name:SHAPHAUN
Middle Name:TAMARA
Last Name:BLACK
Suffix:
Gender:F
Credentials:CSAC
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 681282
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-0023
Mailing Address - Country:US
Mailing Address - Phone:704-965-8119
Mailing Address - Fax:
Practice Address - Street 1:1409 EAST BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5817
Practice Address - Country:US
Practice Address - Phone:980-225-7899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2726101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)