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General NPI Number Information
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NPI Number | 1508120916
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Entity Type | Organization
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Legal Business Name | MELODY BLACK LLC
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Dates
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Enumeration Date | 06/29/2012
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Last Update Date | 06/29/2012
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Provider Practice Location Address
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Address Line | 823 RIDGEFIELD DR
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-2510
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Country | US
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Telephone | 770-789-0274
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Fax | 86-658-8441
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Provider Business Mailing Address
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Address Line | 823 RIDGEFIELD DR
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-2510
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Country | US
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Telephone | 770-789-0274
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Fax | 86-658-8441
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Authorized Official
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Title or Position | PROFESSIONAL COUNSELOR
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Name | MRS. MELODY BLACK
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Credential | L.P.C.
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Telephone | 770-789-0274
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 006648
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License Number State | GA
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