Healthcare Provider Details

I. General information

NPI: 1770971921
Provider Name (Legal Business Name): LAURA ALYCE BLACK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 COMMERCE ST
GREENVILLE NC
27858-5029
US

IV. Provider business mailing address

1220 PAMLICO ST
WASHINGTON NC
27889-3821
US

V. Phone/Fax

Practice location:
  • Phone: 252-321-8080
  • Fax:
Mailing address:
  • Phone: 612-871-1454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC016401
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: