Provider Demographics
NPI:1659724391
Name:KAREN G. BLACK, MARRIAGE AND FAMILY THERAPY, INC.
Entity Type:Organization
Organization Name:KAREN G. BLACK, MARRIAGE AND FAMILY THERAPY, INC.
Other - Org Name:COFFEE HOUSE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:951-445-2105
Mailing Address - Street 1:28465 OLD TOWN FRONT ST STE 221
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-1822
Mailing Address - Country:US
Mailing Address - Phone:951-445-2105
Mailing Address - Fax:866-961-5084
Practice Address - Street 1:28465 OLD TOWN FRONT ST STE 221
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-1822
Practice Address - Country:US
Practice Address - Phone:951-445-2105
Practice Address - Fax:866-961-5084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90128106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty