MEDICARE: DR. TRASHA JACQUETTE BLACK PHD, LPC, NCC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	4047	NC
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	4047	NC
3	101YM0800X	Mental Health Counselor	4047	NC
4	101YP2500X	Professional Counselor	4047	NC

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
2	142A2	OTHER	NC	BCBSNC

General Provider Information

NPI Number	:	1730119363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRASHA JACQUETTE BLACK PHD, LPC, NCC

Provider Business Mailing Address
First Line	:	PO BOX 560723
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28256-0723
Country	:	US
Telephone Number	:	704-596-0505
Fax Number	:	704-596-0507

Provider Business Practice Location Address
First Line	:	5104 REAGAN DR STE 5
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28206-1392
Country	:	US
Telephone Number	:	704-596-0505
Fax Number	:	704-596-0507

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	01/24/2018

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