Provider Demographics
NPI:1497632095
Name:BLACK, LANCE H (LBSW)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:H
Last Name:BLACK
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ROAD 3459
Mailing Address - Street 2:
Mailing Address - City:FLORA VISTA
Mailing Address - State:NM
Mailing Address - Zip Code:87415-9667
Mailing Address - Country:US
Mailing Address - Phone:505-278-3400
Mailing Address - Fax:
Practice Address - Street 1:455 N LIGHT PLANT RD
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-1517
Practice Address - Country:US
Practice Address - Phone:505-334-6102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2025-06571041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool