Basic Information
| Provider Information | |||||||||
| NPI: | 1134550338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | RRW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 S STONEMAN AVE APT 3 | ||||||||
| Address2: | |||||||||
| City: | ALHAMBRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 918015161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9258486937 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 540 S EREMLAND DR | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917233186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269661577 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2013 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RW7051 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.