Provider Demographics
NPI:1326565144
Name:BLACK, VERONICA MICHELLE (CDCA)
Entity Type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:MICHELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 226
Mailing Address - Street 2:218 N. EAST ST
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690
Mailing Address - Country:US
Mailing Address - Phone:740-947-6727
Mailing Address - Fax:740-835-8723
Practice Address - Street 1:14572 US RTE 23
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690
Practice Address - Country:US
Practice Address - Phone:740-947-7581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH080159101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080159Medicaid