MEDICARE: JUANITA ILENE BLACK LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	LMFT84453	CA

General Provider Information

NPI Number	:	1497147235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUANITA ILENE BLACK LMFT

Provider Business Mailing Address
First Line	:	78398 DESERT WILLOW DR
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92211-1323
Country	:	US
Telephone Number	:	562-537-3977
Fax Number	:	267-430-2551

Provider Business Practice Location Address
First Line	:	78398 DESERT WILLOW DR
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92211-1323
Country	:	US
Telephone Number	:	562-537-3977
Fax Number	:	267-430-2551

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2015
Last Update Date	:	12/30/2025

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