Provider Demographics
NPI:1750915286
Name:BLACK, BRITANI SHAYE
Entity type:Individual
Prefix:
First Name:BRITANI
Middle Name:SHAYE
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 1:1115 20TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-2071
Mailing Address - Country:US
Mailing Address - Phone:304-691-1500
Mailing Address - Fax:
Practice Address - Street 1:1115 20TH ST STE 200
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-2071
Practice Address - Country:US
Practice Address - Phone:304-691-1500
Practice Address - Fax:304-523-4358
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1247103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical