Healthcare Provider Details

I. General information

NPI: 1104129840
Provider Name (Legal Business Name): KATHRYN R BLACK LAC, MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2010
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2258 SANTA CLARA AVE STE 1
ALAMEDA CA
94501-4473
US

IV. Provider business mailing address

1966 TICE VALLEY BLVD # 228
WALNUT CREEK CA
94595-2203
US

V. Phone/Fax

Practice location:
  • Phone: 510-814-6900
  • Fax:
Mailing address:
  • Phone: 480-818-4277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number17203
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number08011
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: