Provider Demographics
NPI:1609956630
Name:C-BLAC SERVICES, INC.
Entity type:Organization
Organization Name:C-BLAC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JANET
Authorized Official - Middle Name:M
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, CSAC, LCAS
Authorized Official - Phone:919-989-1786
Mailing Address - Street 1:PO BOX 1629
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-1629
Mailing Address - Country:US
Mailing Address - Phone:919-989-1786
Mailing Address - Fax:919-989-1791
Practice Address - Street 1:1302 W MARKET ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-3339
Practice Address - Country:US
Practice Address - Phone:919-989-1786
Practice Address - Fax:919-989-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 051-128101YA0400X, 101YM0800X, 2084P0802X, 251B00000X, 251E00000X, 251K00000X, 251S00000X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL 051-128OtherMENTAL HEALTH LICENSE