Basic Information
| Provider Information | |||||||||
| NPI: | 1841674421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | ANNA KATHERINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2708 W OXFORD LOOP | ||||||||
| Address2: | STE 115 | ||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386555724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622347521 | ||||||||
| FaxNumber: | 6622363071 | ||||||||
| Practice Location | |||||||||
| Address1: | 2708 W OXFORD LOOP STE 115 | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386555724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622590868 | ||||||||
| FaxNumber: | 6623805036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2015 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.