Healthcare Provider Details

I. General information

NPI: 1801532908
Provider Name (Legal Business Name): MASAI A BLACK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2244 EXECUTIVE DR
HAMPTON VA
23666-2430
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-827-1001
  • Fax: 757-827-3128
Mailing address:
  • Phone: 757-316-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701011062
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: