Provider Demographics
NPI:1770600165
Name:BLACK, DEBBY (PLPC)
Entity type:Individual
Prefix:
First Name:DEBBY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 E CANTEBURY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2603
Mailing Address - Country:US
Mailing Address - Phone:417-459-6591
Mailing Address - Fax:
Practice Address - Street 1:104 B. WEST JACKSON STREET
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613
Practice Address - Country:US
Practice Address - Phone:417-777-1458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004032564101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional