Provider Demographics
NPI:1376802397
Name:BLACK, THERESA L (LPC, NCC, ACS)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:LPC, NCC, ACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 IRVING AVE
Mailing Address - Street 2:CAPC FIRST FLOOR
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-2123
Mailing Address - Country:US
Mailing Address - Phone:856-575-4196
Mailing Address - Fax:856-575-5071
Practice Address - Street 1:333 IRVING AVE
Practice Address - Street 2:CAPC FIRST FLOOR
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-2123
Practice Address - Country:US
Practice Address - Phone:856-575-4196
Practice Address - Fax:856-575-5071
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00324200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3674509Medicaid