Provider Demographics
NPI:1346545605
Name:BLACK, CAMILLA YVETTE (MED, NCC,LPC)
Entity Type:Individual
Prefix:MS
First Name:CAMILLA
Middle Name:YVETTE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MED, NCC,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241-06 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587
Mailing Address - Country:US
Mailing Address - Phone:919-554-1231
Mailing Address - Fax:919-554-2406
Practice Address - Street 1:1241-06 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587
Practice Address - Country:US
Practice Address - Phone:919-554-1231
Practice Address - Fax:919-554-2406
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8316101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional