Provider Demographics
NPI:1467035998
Name:BLACK, JULIE ANN (MHC-LP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MADISON AVE FL 8
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-2418
Mailing Address - Country:US
Mailing Address - Phone:917-810-9890
Mailing Address - Fax:
Practice Address - Street 1:260 MADISON AVE FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2418
Practice Address - Country:US
Practice Address - Phone:917-810-9890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP05589101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP05589OtherPRIVATE