Healthcare Provider Details

I. General information

NPI: 1548101538
Provider Name (Legal Business Name): ANTOINETTE BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TONI BLACK

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4304 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4811
US

IV. Provider business mailing address

205 GIRARD BLVD SE
ALBUQUERQUE NM
87106-2229
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-7561
  • Fax:
Mailing address:
  • Phone: 505-614-6268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: