Basic Information
| Provider Information | |||||||||
| NPI: | 1750915286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | BRITANI | ||||||||
| MiddleName: | SHAYE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 20TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257032071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 20TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257032071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911500 | ||||||||
| FaxNumber: | 3045234358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1247 | WV | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.