MEDICARE: HER BLACK THERAPIST LCSW P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor
3	104100000X	Social Worker
4	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457973539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HER BLACK THERAPIST LCSW P.C.

Provider Business Mailing Address
First Line	:	1080 BERGEN ST STE 122
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-3340
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1080 BERGEN ST STE 122
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-3340
Country	:	US
Telephone Number	:	929-429-4733
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ CEO
Name	:	KALISHA SMITH
Credential	:	LCSW CASAC
Telephone Number	:	929-429-4733

Provider Enumeration Date	:	05/12/2020
Last Update Date	:	01/19/2021

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