Provider Demographics
NPI:1780124560
Name:BLACK, MICHAEL W (LMHC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:BLACK
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 DAVID WALKER DR # 237
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6172
Mailing Address - Country:US
Mailing Address - Phone:352-910-6915
Mailing Address - Fax:
Practice Address - Street 1:2880 DAVID WALKER DR # 237
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6172
Practice Address - Country:US
Practice Address - Phone:352-910-6915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2024-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH19330101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health