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Individual
GEORGIA ROSE BLACK
Active
Individual
GEORGIA ROSE BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MS
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
4665
WI
221700000X
Art Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1497378947
—
WI
Enumeration date
05/19/2020
Last updated
01/18/2022
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