Provider Demographics
NPI:1558841015
Name:BLACK, RENEISHA LACHELLE (LPCA)
Entity Type:Individual
Prefix:
First Name:RENEISHA
Middle Name:LACHELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8119 SOLACE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-3214
Mailing Address - Country:US
Mailing Address - Phone:704-577-1135
Mailing Address - Fax:
Practice Address - Street 1:8119 SOLACE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-3214
Practice Address - Country:US
Practice Address - Phone:704-577-1135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14097101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional