Provider Demographics
NPI:1477604494
Name:BLACK, DENISE R (LCSW)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT ROAD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-364-7000
Mailing Address - Fax:
Practice Address - Street 1:3495 PIEDMONT ROAD NE I
Practice Address - Street 2:DEPARTMENT OF BEHAVIORAL HEALTH
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305
Practice Address - Country:US
Practice Address - Phone:404-364-7243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0023241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
80BBFVLMedicare ID - Type Unspecified
Q24982Medicare UPIN