MEDICARE: KATHRYN R BLACK LAC, MT-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	17203	CA
2	225A00000X	Music Therapist	08011	UT

General Provider Information

NPI Number	:	1104129840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN R BLACK LAC, MT-BC

Provider Business Mailing Address
First Line	:	1966 TICE VALLEY BLVD # 228
Second Line	:
City	:	WALNUT CREEK
State	:	CA
Zip	:	94595-2203
Country	:	US
Telephone Number	:	480-818-4277
Fax Number	:

Provider Business Practice Location Address
First Line	:	2258 SANTA CLARA AVE STE 1
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94501-4473
Country	:	US
Telephone Number	:	510-814-6900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2010
Last Update Date	:	06/09/2016

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