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General NPI Number Information
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NPI Number | 1619992054
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Entity Type | Individual
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Provider Name | SANDRA L BLACK MA, LPC
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Gender | Female
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Dates
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Enumeration Date | 07/13/2006
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Last Update Date | 10/27/2015
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Provider Practice Location Address
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Address Line | 4200 SOUTH HULEN STREET SUITE 658
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City | FORT WORTH
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State | TX
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Zip | 76109
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Country | US
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Telephone | 817-673-3999
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Fax | 817-570-0370
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Provider Business Mailing Address
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Address Line | 4200 SOUTH HULEN STREET SUITE 658
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City | FORT WORTH
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State | TX
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Zip | 76109
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Country | US
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Telephone | 817-673-3999
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Fax | 817-570-0370
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 13288
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC13288
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License Number State | TX
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