Provider Demographics
NPI:1629207626
Name:BLACK, MICAELA T (LMHC)
Entity Type:Individual
Prefix:MISS
First Name:MICAELA
Middle Name:T
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 N CHRISTOPHER AVE
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-3885
Mailing Address - Country:US
Mailing Address - Phone:401-255-4299
Mailing Address - Fax:
Practice Address - Street 1:107 CLOCK TOWER SQ
Practice Address - Street 2:SUITE 107
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-1396
Practice Address - Country:US
Practice Address - Phone:401-255-4299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-11
Last Update Date:2009-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00421101YM0800X
RI0005601171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator