MEDICARE: EMILY VAUGHN BLACK LCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	14643	NC
2	101YM0800X	Mental Health Counselor	14643	NC
3	101YP2500X	Professional Counselor	14643	NC

General Provider Information

NPI Number	:	1427516996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY VAUGHN BLACK LCMHC

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 MATTHEWS TOWNSHIP PKWY STE 320
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-5403
Country	:	US
Telephone Number	:	704-384-1261
Fax Number	:	704-384-3145

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2019
Last Update Date	:	05/26/2026

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