Healthcare Provider Details

I. General information

NPI: 1255286886
Provider Name (Legal Business Name): ISAAC BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ISAAC BLACKREACH MA, RI

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1548 W CAYUSE CREEK DR STE 100
MERIDIAN ID
83646-4795
US

IV. Provider business mailing address

1260 E ARROW HWY
UPLAND CA
91786-4982
US

V. Phone/Fax

Practice location:
  • Phone: 208-600-2072
  • Fax:
Mailing address:
  • Phone: 909-932-1069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2081038
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: