Healthcare Provider Details

I. General information

NPI: 1437076205
Provider Name (Legal Business Name): CHADD MYKELL BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 APEX LOOP FOLSOM APT. 203
FOLSOM CA
95630
US

IV. Provider business mailing address

159 APEX LOOP FOLSOM APT. 203
FOLSOM CA
95630
US

V. Phone/Fax

Practice location:
  • Phone: 559-410-5478
  • Fax:
Mailing address:
  • Phone: 559-410-5478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: