Healthcare Provider Details

I. General information

NPI: 1881867299
Provider Name (Legal Business Name): ELISHA BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S 13TH ST STE 209
GROVER BEACH CA
93433-2263
US

IV. Provider business mailing address

791 PRICE ST # 307
PISMO BEACH CA
93449-2529
US

V. Phone/Fax

Practice location:
  • Phone: 805-252-9220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number85171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: