MEDICARE: BECKY E BLACK RD

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	133V00000X	Registered Dietitian	709236	CA
2	106H00000X	Marriage & Family Therapist	36620	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1831416460	OTHER	OR	NOT SURE HOW TO ANSWER THIS

General Provider Information

NPI Number	:	1831416460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BECKY E BLACK RD

Provider Business Mailing Address
First Line	:	1772 SANTA CRUZ ST
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-3352
Country	:	US
Telephone Number	:	949-290-4016
Fax Number	:

Provider Business Practice Location Address
First Line	:	1772 SANTA CRUZ ST
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-3352
Country	:	US
Telephone Number	:	949-290-4016
Fax Number	:

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

Provider Enumeration Date	:	04/21/2010
Last Update Date	:	01/06/2023

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