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General NPI Number Information
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NPI Number | 1063997237
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Entity Type | Individual
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Provider Name | KIMBERLY ROCHELLE BLACK LPC;LCAS-A
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Gender | Female
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Dates
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Enumeration Date | 10/03/2018
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Last Update Date | 10/03/2018
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Provider Practice Location Address
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Address Line | 31 E MAIN AVE
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City | TAYLORSVILLE
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State | NC
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Zip | 28681-2540
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Country | US
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Telephone | 704-872-0234
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1545
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City | STATESVILLE
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State | NC
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Zip | 28687-1545
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 24177
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 12214
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License Number State | NC
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