Provider Demographics
NPI:1649451113
Name:BLACK, DONNA MARIA (LCSW)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIA
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-450-0310
Mailing Address - Fax:601-450-0321
Practice Address - Street 1:605 STADIUM DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-4156
Practice Address - Country:US
Practice Address - Phone:601-450-0310
Practice Address - Fax:601-450-0321
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC0468104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05723875Medicaid
MS302I807848Medicare PIN