Provider Demographics
NPI:1730457474
Name:BLACK, MELODY KAREN (BS, MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:MELODY
Middle Name:KAREN
Last Name:BLACK
Suffix:
Gender:F
Credentials:BS, MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2594 HIGHWAY 34 E
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1328
Mailing Address - Country:US
Mailing Address - Phone:770-252-3760
Mailing Address - Fax:678-298-7637
Practice Address - Street 1:2594 HIGHWAY 34 E
Practice Address - Street 2:SUITE B
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1328
Practice Address - Country:US
Practice Address - Phone:770-252-3760
Practice Address - Fax:678-298-7637
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006648101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional