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General NPI Number Information
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NPI Number | 1265251094
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Entity Type | Organization
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Legal Business Name | BLACKBIRD AND CORNERSTONE LLC
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Dates
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Enumeration Date | 10/08/2024
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 326 MYRTLE CROSSING DR
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City | STATESBORO
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State | GA
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Zip | 30458-4688
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Country | US
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Telephone | 912-489-7590
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Fax |
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Provider Business Mailing Address
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Address Line | 175 PAT MOCK ROAD
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City | STATESBORO
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State | GA
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Zip | 30458-6483
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Country | US
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Telephone | 912-618-9568
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Fax |
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Authorized Official
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Title or Position | LICENSED PROFESSIONAL COUNSELOR
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Name | MRS. CARLY MELISSA MOCK
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Credential | LPC, MS
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Telephone | 912-618-9568
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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