Provider Demographics
NPI:1043322068
Name:BLACK, RANDALL CARL (LCSW)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:CARL
Last Name:BLACK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 CALICO CANYON LN
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-5574
Mailing Address - Country:US
Mailing Address - Phone:281-450-7724
Mailing Address - Fax:866-642-6202
Practice Address - Street 1:1610 CALICO CANYON LN
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5574
Practice Address - Country:US
Practice Address - Phone:281-450-7724
Practice Address - Fax:866-642-6202
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS23276104100000X, 1041C0700X
TX23276171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX356407Medicare UPIN