Provider Demographics
NPI:1255159620
Name:BLACK, MARY EKATERINA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:EKATERINA
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 1:1087 LITTLE RUTH RD
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-8914
Mailing Address - Country:US
Mailing Address - Phone:904-626-0188
Mailing Address - Fax:
Practice Address - Street 1:2561 COUNTY ROAD 220 STE 304
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8518
Practice Address - Country:US
Practice Address - Phone:904-626-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health