Provider Demographics
NPI:1770971921
Name:BLACK, LAURA ALYCE (LCSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ALYCE
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 1:1220 PAMLICO ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3821
Mailing Address - Country:US
Mailing Address - Phone:612-871-1454
Mailing Address - Fax:
Practice Address - Street 1:231 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5029
Practice Address - Country:US
Practice Address - Phone:252-321-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0164011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical