Provider Demographics
NPI:1710478060
Name:BLACK, BENJAMIN ROBERT (MSW)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:BLACK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-4708
Mailing Address - Country:US
Mailing Address - Phone:650-372-4080
Mailing Address - Fax:
Practice Address - Street 1:564 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-4708
Practice Address - Country:US
Practice Address - Phone:650-503-4589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW1004641041C0700X
CAASW85095101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor