Provider Demographics
NPI:1609625201
Name:BLACK, KANEISHA (PSYD)
Entity type:Individual
Prefix:
First Name:KANEISHA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 WILDLIFE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-3464
Mailing Address - Country:US
Mailing Address - Phone:704-763-7479
Mailing Address - Fax:
Practice Address - Street 1:710 WILDLIFE LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-3464
Practice Address - Country:US
Practice Address - Phone:704-763-7479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty