MEDICARE: OLIVE BEAR BLACKWOOD LMFTA

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	101YM0800X	Mental Health Counselor
2	106H00000X	Marriage & Family Therapist	10427A	NC
3	101YP2500X	Professional Counselor
4	103TA0700X	Adult Development & Aging Psychologist
5	103TF0000X	Family Psychologist

General Provider Information

NPI Number	:	1891550315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVE BEAR BLACKWOOD LMFTA

Provider Business Mailing Address
First Line	:	PO BOX 77964
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28271-7022
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	811 CENTRAL AVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2032
Country	:	US
Telephone Number	:	980-236-0734
Fax Number	:

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

Provider Enumeration Date	:	02/14/2024
Last Update Date	:	08/02/2024

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