Provider Demographics
NPI:1578935409
Name:BLACK, SUSAN (BCBA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16782 VON KARMAN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2417
Mailing Address - Country:US
Mailing Address - Phone:855-223-7123
Mailing Address - Fax:619-374-7134
Practice Address - Street 1:12604 HIDDENCREEK WAY STE C
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2137
Practice Address - Country:US
Practice Address - Phone:562-760-4429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-15-19264103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst