Basic Information
| Provider Information | |||||||||
| NPI: | 1922139872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | GABRIEL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PLPE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2904 ARKANSAS BLVD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718542536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707734655 | ||||||||
| FaxNumber: | 8707724650 | ||||||||
| Practice Location | |||||||||
| Address1: | 1658 HWY 371 WEST | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708873660 | ||||||||
| FaxNumber: | 8708873705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | 09-63AE-PL | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.