Provider Demographics
NPI:1457401929
Name:BLACK, TOMMY DEAN JR (EDS, LPC)
Entity Type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:DEAN
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:EDS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-3606
Mailing Address - Country:US
Mailing Address - Phone:912-876-4010
Mailing Address - Fax:912-369-2262
Practice Address - Street 1:215 E COURT ST
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3606
Practice Address - Country:US
Practice Address - Phone:912-876-4010
Practice Address - Fax:912-369-2262
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003476101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health