Provider Demographics
NPI:1184472573
Name:BLACK SERENE, PLLC
Entity type:Organization
Organization Name:BLACK SERENE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER/LEAD COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:DAZZMEN
Authorized Official - Middle Name:NIKOLE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC, LPC
Authorized Official - Phone:404-649-5274
Mailing Address - Street 1:2108 SOUTH BLVD STE 211
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5099
Mailing Address - Country:US
Mailing Address - Phone:404-649-5274
Mailing Address - Fax:
Practice Address - Street 1:4306 N SHALLOWFORD RD APT 2216
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-1158
Practice Address - Country:US
Practice Address - Phone:404-649-5274
Practice Address - Fax:404-726-4881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-09
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service