Healthcare Provider Details

I. General information

NPI: 1386640159
Provider Name (Legal Business Name): DAVID L. BLACK PSY.D., LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 E BRADFORD PKWY STE 210-4
SPRINGFIELD MO
65804-6566
US

IV. Provider business mailing address

1531 E BRADFORD PKWY STE 210-4
SPRINGFIELD MO
65804-6566
US

V. Phone/Fax

Practice location:
  • Phone: 417-890-4083
  • Fax: 417-890-4091
Mailing address:
  • Phone: 417-890-4083
  • Fax: 417-890-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2001004284
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number2009026793
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2001004284
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number2009026793
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2009026793
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number2009026793
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2009026793
License Number StateMO
# 8
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2009026793
License Number StateMO
# 9
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2009026793
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: