Provider Demographics
NPI:1851288492
Name:BLACK, TAMMIE LYNN (MSW-CC)
Entity type:Individual
Prefix:
First Name:TAMMIE
Middle Name:LYNN
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 VARNUM POND RD
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:ME
Mailing Address - Zip Code:04984-3003
Mailing Address - Country:US
Mailing Address - Phone:207-778-1080
Mailing Address - Fax:
Practice Address - Street 1:284 MAIN ST STE 280
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:ME
Practice Address - Zip Code:04294-3044
Practice Address - Country:US
Practice Address - Phone:207-200-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC24774101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health