Provider Demographics
NPI:1821509415
Name:BLACK, MATTHEW DAVID (LPC, CDCA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:BLACK
Suffix:
Gender:M
Credentials:LPC, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 NOBLE DR
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-5353
Mailing Address - Country:US
Mailing Address - Phone:330-264-3232
Mailing Address - Fax:
Practice Address - Street 1:17606 COSHOCTON RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9218
Practice Address - Country:US
Practice Address - Phone:740-397-7568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.163972101YA0400X
OHC.1500475101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)