Provider Demographics
NPI:1467024497
Name:BLACK, LAUREL FAYE (MSSW)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:FAYE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 BUCHANON DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-3348
Mailing Address - Country:US
Mailing Address - Phone:206-473-0173
Mailing Address - Fax:
Practice Address - Street 1:1445 BUCHANON DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-3348
Practice Address - Country:US
Practice Address - Phone:206-473-0173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker