Healthcare Provider Details

I. General information

NPI: 1306203575
Provider Name (Legal Business Name): ROBIN BLACK M.A., CCC, SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 VENTURA BLVD SUITE 600
ENCINO CA
91436-2203
US

IV. Provider business mailing address

11750 W SUNSET BLVD 115
LOS ANGELES CA
90049-2960
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-1977
  • Fax:
Mailing address:
  • Phone: 310-925-1839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP5019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: