Provider Demographics
NPI:1689867806
Name:BLACK, ALEX REN
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:REN
Last Name:BLACK
Suffix:
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 1:2540 CHARLESTON ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-2508
Mailing Address - Country:US
Mailing Address - Phone:510-292-0139
Mailing Address - Fax:510-268-3770
Practice Address - Street 1:2540 CHARLESTON ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-2508
Practice Address - Country:US
Practice Address - Phone:510-292-0139
Practice Address - Fax:510-268-3770
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist