Provider Demographics
NPI:1750607677
Name:BLACK, MICHELLE (LCDP, LMHC-A)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCDP, LMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 WAMPANOAG TRL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-1504
Mailing Address - Country:US
Mailing Address - Phone:401-246-1195
Mailing Address - Fax:
Practice Address - Street 1:610 WAMPANOAG TRL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-1504
Practice Address - Country:US
Practice Address - Phone:401-246-1195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00206-A101YM0800X
RICDP00634101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health