Provider Demographics
NPI:1497479596
Name:BLACK, HAGAN
Entity Type:Individual
Prefix:
First Name:HAGAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 INVERNESS DR
Mailing Address - Street 2:
Mailing Address - City:LA CANADA FLINTRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91011-4144
Mailing Address - Country:US
Mailing Address - Phone:323-640-5282
Mailing Address - Fax:
Practice Address - Street 1:9024 HARRATT ST
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-3804
Practice Address - Country:US
Practice Address - Phone:323-640-5282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI36260822101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11818Medicaid