Provider Demographics
NPI:1376872697
Name:BLACK, KEELY CHANTALE
Entity Type:Individual
Prefix:MS
First Name:KEELY
Middle Name:CHANTALE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3227 MCKINNEY AVE
Mailing Address - Street 2:6E
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-7424
Mailing Address - Country:US
Mailing Address - Phone:972-977-2490
Mailing Address - Fax:
Practice Address - Street 1:3227 MCKINNEY AVE
Practice Address - Street 2:6E
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-7424
Practice Address - Country:US
Practice Address - Phone:972-977-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62324101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional