Provider Demographics
NPI:1457687600
Name:BLACK, TONYA MARIE (MA, LMFT, LMHC, CMHS)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA, LMFT, LMHC, CMHS
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 3991
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98509-3991
Mailing Address - Country:US
Mailing Address - Phone:360-628-1295
Mailing Address - Fax:
Practice Address - Street 1:2142 W RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-7813
Practice Address - Country:US
Practice Address - Phone:360-628-1295
Practice Address - Fax:360-427-7980
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health