Provider Demographics
NPI:1508120916
Name:MELODY BLACK LLC
Entity Type:Organization
Organization Name:MELODY BLACK LLC
Other - Org Name:HEART MATTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:770-789-0274
Mailing Address - Street 1:823 RIDGEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-2510
Mailing Address - Country:US
Mailing Address - Phone:770-789-0274
Mailing Address - Fax:086-658-8441
Practice Address - Street 1:823 RIDGEFIELD DR
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-2510
Practice Address - Country:US
Practice Address - Phone:770-789-0274
Practice Address - Fax:086-658-8441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006648251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003119695AMedicaid