MEDICARE: DR. DAVID L. BLACK PSY.D., LCSW

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	1041C0700X	Clinical Social Worker	2001004284	MO
2	103TH0100X	Health Service Psychologist	2009026793	MO
3	106H00000X	Marriage & Family Therapist	2001004284	MO
4	103TA0400X	Addiction (Substance Use Disorder) Psychologist	2009026793	MO
5	103TB0200X	Cognitive & Behavioral Psychologist	2009026793	MO
6	103TP2701X	Group Psychotherapy Psychologist	2009026793	MO
7	103TC1900X	Counseling Psychologist	2009026793	MO
8	103TC0700X	Clinical Psychologist	2009026793	MO
9	103TC2200X	Clinical Child & Adolescent Psychologist	2009026793	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386640159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID L. BLACK PSY.D., LCSW

Provider Business Mailing Address
First Line	:	1531 E BRADFORD PKWY
Second Line	:	STE 210-4
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-6566
Country	:	US
Telephone Number	:	417-890-4083
Fax Number	:	417-890-4091

Provider Business Practice Location Address
First Line	:	1531 E BRADFORD PKWY
Second Line	:	STE 210-4
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-6566
Country	:	US
Telephone Number	:	417-890-4083
Fax Number	:	417-890-4091

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

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	04/21/2011

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