Provider Demographics
NPI:1902301427
Name:BLACK, GLENDA CAROL (LMHC, CASAC-2)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:CAROL
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMHC, CASAC-2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E HARTSDALE AVE APT 3IW
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-3971
Mailing Address - Country:US
Mailing Address - Phone:646-238-2409
Mailing Address - Fax:
Practice Address - Street 1:109 W 38TH ST RM 303
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-3643
Practice Address - Country:US
Practice Address - Phone:212-960-8626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31636101YA0400X
NY007387101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)