Provider Demographics
NPI:1437685849
Name:BLACK, ALEXANDER LESLIE JR
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:LESLIE
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ALEXANDER
Other - Middle Name:LESLIE
Other - Last Name:BLACK
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MSW LCSW
Mailing Address - Street 1:700 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-6341
Mailing Address - Country:US
Mailing Address - Phone:805-610-5431
Mailing Address - Fax:
Practice Address - Street 1:31625 HIGHWAY 101 S
Practice Address - Street 2:
Practice Address - City:SOLEDAD
Practice Address - State:CA
Practice Address - Zip Code:93960-9529
Practice Address - Country:US
Practice Address - Phone:831-678-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS9337171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQW1234Medicare PIN