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NPI Code Detail

MEDICARE: SUSAN BLACK BCBA

MEDICARE: SUSAN BLACK BCBA
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
1103K00000XBehavior Analyst1-15-19264CA

General Provider Information

NPI Number : 1578935409
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN BLACK BCBA
Provider Business Mailing Address
First Line : 16782 VON KARMAN AVE STE 11
Second Line :
City : IRVINE
State : CA
Zip : 92606-2417
Country : US
Telephone Number : 855-223-7123
Fax Number : 619-374-7134
Provider Business Practice Location Address
First Line : 12604 HIDDENCREEK WAY STE C
Second Line :
City : CERRITOS
State : CA
Zip : 90703-2137
Country : US
Telephone Number : 562-760-4429
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/30/2015
Last Update Date : 11/13/2020

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