Healthcare Provider Details

I. General information

NPI: 1013846906
Provider Name (Legal Business Name): GABRIEALLA BLACK LPC
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 EDGEWOOD AVE
KIRKWOOD MO
63122-6223
US

IV. Provider business mailing address

710 EDGEWOOD AVE
KIRKWOOD MO
63122-6223
US

V. Phone/Fax

Practice location:
  • Phone: 601-529-8916
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2026019953
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: