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4601 66th St Ste E Lubbock TX 79414-4875 | |
| (806) 712-5225 | |
| (806) 722-5225 |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 4601 66th St Ste E, Lubbock, Texas |
| Authorized Official Name and Position | Nicole Black (MANAGING PARTNER) |
| Authorized Official Contact | 8067125225 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4601 66th St Ste E Lubbock TX 79414-4875 Ph: (806) 712-5225 | 4601 66th St Ste E Lubbock TX 79414-4875 Ph: (806) 712-5225 |
| NPI Number | 1780270173 |
|---|---|
| Provider Enumeration Date | 12/18/2020 |
| Last Update Date | 07/29/2024 |
| Certification Date | 07/29/2024 |
| Medicare PECOS PAC ID | 6901330513 |
|---|---|
| Medicare Enrollment ID | O20241105001715 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1780270173 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | (* (Not Available)) | Primary |
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Secondary |
| Provider Name | Nicole Lynn Black |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1477935351 PECOS PAC ID: 7719411321 Enrollment ID: I20241105001879 |
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