Provider Demographics
NPI:1417189846
Name:BLACK, STEPHEN THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:THOMAS
Last Name:BLACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 EDGEMAR AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-2319
Mailing Address - Country:US
Mailing Address - Phone:650-359-1678
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY CIR
Practice Address - Street 2:CSU STANISLAUS
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-3200
Practice Address - Country:US
Practice Address - Phone:209-667-3065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21055103T00000X
MSPSY 46754103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist