Provider Demographics
NPI:1659616365
Name:BLACK, L. DIANE (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:L. DIANE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:NEW BADEN
Mailing Address - State:TX
Mailing Address - Zip Code:77870-0069
Mailing Address - Country:US
Mailing Address - Phone:979-299-8315
Mailing Address - Fax:
Practice Address - Street 1:4301 CARTER CREEK PKWY
Practice Address - Street 2:SUITE 212
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-4485
Practice Address - Country:US
Practice Address - Phone:979-299-8315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200999106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist