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General NPI Number Information
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NPI Number | 1184472573
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Entity Type | Organization
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Legal Business Name | BLACK SERENE, PLLC
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Dates
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Enumeration Date | 05/09/2024
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Last Update Date | 09/20/2025
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Provider Practice Location Address
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Address Line | 3350 FOOTBRIDGE LN STE 124 #524
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City | FAYETTEVILLE
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State | NC
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Zip | 28306-9695
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Country | US
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Telephone | 404-649-5274
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Fax |
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Provider Business Mailing Address
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Address Line | 3350 FOOTBRIDGE LN STE 124
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City | FAYETTEVILLE
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State | NC
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Zip | 28306-9695
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Country | US
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Telephone | 404-649-5274
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Fax | 404-726-4881
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Authorized Official
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Title or Position | PRACTICE OWNER/LICENSED COUNSELOR
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Name | DAZZMEN NIKOLE DAVIS
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Credential | LCMHC, LPC
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Telephone | 404-649-5274
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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