Provider Demographics
NPI:1790803674
Name:BLACK, JAMES C (MA CLINICAL PSY)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:C
Last Name:BLACK
Suffix:
Gender:M
Credentials:MA CLINICAL PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 W HAMLET AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLET
Mailing Address - State:NC
Mailing Address - Zip Code:28345-2507
Mailing Address - Country:US
Mailing Address - Phone:910-582-7046
Mailing Address - Fax:910-582-7106
Practice Address - Street 1:815 W HAMLET AVE
Practice Address - Street 2:
Practice Address - City:HAMLET
Practice Address - State:NC
Practice Address - Zip Code:28345-2507
Practice Address - Country:US
Practice Address - Phone:910-582-7046
Practice Address - Fax:910-582-7106
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1119103TC2200X
SC0762106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC046NJOtherBLUECROSS BLUESHIELD
NC3403400Medicaid