Provider Demographics
NPI:1659144350
Name:BLACK DIAMOND PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:BLACK DIAMOND PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:331-253-2399
Mailing Address - Street 1:13220 FOX LN
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-9174
Mailing Address - Country:US
Mailing Address - Phone:909-312-2646
Mailing Address - Fax:
Practice Address - Street 1:13220 FOX LN
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439
Practice Address - Country:US
Practice Address - Phone:331-253-2399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-03
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty