Provider Demographics
NPI:1770192379
Name:BLACK, AMELIA (PHD, CGP)
Entity Type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CEB 226 4505 S. MARYLAND PKWY
Mailing Address - Street 2:BOX #453033
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89154
Mailing Address - Country:US
Mailing Address - Phone:702-895-1532
Mailing Address - Fax:
Practice Address - Street 1:CEB 226 4505 S. MARYLAND PKWY
Practice Address - Street 2:BOX #453033
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89154
Practice Address - Country:US
Practice Address - Phone:702-895-1532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0928103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist