Provider Demographics
NPI:1205624715
Name:BLACK, MICKENZIE RENEE (LSW)
Entity type:Individual
Prefix:
First Name:MICKENZIE
Middle Name:RENEE
Last Name:BLACK
Suffix:
Gender:
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3218 ELM DR
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16105-1104
Mailing Address - Country:US
Mailing Address - Phone:724-856-1837
Mailing Address - Fax:
Practice Address - Street 1:121 ENCLAVE DR STE C
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16105-3207
Practice Address - Country:US
Practice Address - Phone:724-657-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-26
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health