Provider Demographics
NPI:1750749578
Name:BLACK, TINA (LCSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
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 1:4200 NORTHSIDE PKWY NW BLDG 7
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-3007
Mailing Address - Country:US
Mailing Address - Phone:404-442-2348
Mailing Address - Fax:
Practice Address - Street 1:4200 NORTHSIDE PKWY NW BLDG 7
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-3007
Practice Address - Country:US
Practice Address - Phone:404-442-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0041851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical