Provider Demographics
NPI:1730119363
Name:BLACK, TRASHA JACQUETTE (PHD, LPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:TRASHA
Middle Name:JACQUETTE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 560723
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28256-0723
Mailing Address - Country:US
Mailing Address - Phone:704-596-0505
Mailing Address - Fax:704-596-0507
Practice Address - Street 1:5104 REAGAN DR STE 5
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-1392
Practice Address - Country:US
Practice Address - Phone:704-596-0505
Practice Address - Fax:704-596-0507
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4047101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102098Medicaid
NC142A2OtherBCBSNC