Basic Information
| Provider Information | |||||||||
| NPI: | 1871714352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | KATHY | ||||||||
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| Credential: | CADC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15019 ROVING WAY | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959499708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302739541 | ||||||||
| FaxNumber: | 5302737740 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 HENDERSON ST STE C | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959457374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302739541 | ||||||||
| FaxNumber: | 5302737740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YA0400X | C4001407 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.