Basic Information
| Provider Information | |||||||||
| NPI: | 1003373713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | APPC 8336 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 995 GATEWAY CENTER WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193982156 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 995 GATEWAY CENTER WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193982156 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2019 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | APCC8336 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.