Provider Demographics
NPI:1740412410
Name:BLACK, DAVID S (CMHT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:BLACK
Suffix:
Gender:M
Credentials:CMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-2235
Mailing Address - Country:US
Mailing Address - Phone:601-705-1901
Mailing Address - Fax:
Practice Address - Street 1:727 W 21ST ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2235
Practice Address - Country:US
Practice Address - Phone:601-705-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0682101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health