Provider Demographics
NPI:1598253130
Name:BLACK, GUY SR
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:
Last Name:BLACK
Suffix:SR
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 1:3200 ADELINE ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2407
Mailing Address - Country:US
Mailing Address - Phone:510-601-0203
Mailing Address - Fax:
Practice Address - Street 1:3200 ADELINE ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2407
Practice Address - Country:US
Practice Address - Phone:510-601-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator