MEDICARE: DR. LISA BLACK PSYD

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	103TC0700X	Clinical Psychologist	PSY29110	CA

General Provider Information

NPI Number	:	1609302678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA BLACK PSYD

Provider Business Mailing Address
First Line	:	740 FRONT ST STE 130
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-4536
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	740 FRONT ST STE 130
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-4536
Country	:	US
Telephone Number	:	318-295-8118
Fax Number	:

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

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	08/22/2023

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