Basic Information
| Provider Information | |||||||||
| NPI: | 1518300946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCADC-S, LCPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLACK | ||||||||
| OtherFirstName: | PEGGY | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCADC-S | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 201 W CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934584303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028581986 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 W CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934584303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059222243 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2013 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 00464-LC | NV | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | CP-0215 | NV | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 00184-LCS | NV | N | Behavioral Health & Social Service Providers | Counselor | Professional | 225400000X | CP-0215 | NV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 101YM0800X | 00184-LCS | NV | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1518300946 | 05 | NV | MEDICAID |