=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649844176
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN DAVID BLACK JR. MHRT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2021
-----------------------------------------------------
Last Update Date | 05/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2249 N.M YALE STREET
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-877-7303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 634B EUCLID AVE
-----------------------------------------------------
City | DUARTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91010-3110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-877-7303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------