Provider Demographics
NPI:1578014395
Name:BLACK PINE COUNSELING CENTER
Entity Type:Organization
Organization Name:BLACK PINE COUNSELING CENTER
Other - Org Name:BLACK PINE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:757-595-3455
Mailing Address - Street 1:727 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1507
Mailing Address - Country:US
Mailing Address - Phone:757-595-3455
Mailing Address - Fax:757-595-3456
Practice Address - Street 1:727 J CLYDE MORRIS BLVD STE A
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601
Practice Address - Country:US
Practice Address - Phone:757-595-3455
Practice Address - Fax:757-595-3456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA701006460101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA701006460OtherSTATE LICENSE