Basic Information
| Provider Information | |||||||||
| NPI: | 1336337732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | KATHERINE | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1436 | ||||||||
| Address2: | |||||||||
| City: | MORGAN HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950381436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316477652 | ||||||||
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| Practice Location | |||||||||
| Address1: | 299 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MARINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939336003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316477652 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 10/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | ASW59562 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | LCSW79673 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.