Provider Demographics
NPI:1851008932
Name:BLACK, KIMBERLY DANIELLE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DANIELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6218 RIDDLE CT
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-3719
Mailing Address - Country:US
Mailing Address - Phone:404-484-7889
Mailing Address - Fax:
Practice Address - Street 1:2801 BUFORD HWY NE STE 501
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2137
Practice Address - Country:US
Practice Address - Phone:770-696-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist