Provider Demographics
NPI:1851016380
Name:BLACK, ANGELA (CFLE-P)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:CFLE-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2765 S 1200 W
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-4224
Mailing Address - Country:US
Mailing Address - Phone:435-740-1490
Mailing Address - Fax:
Practice Address - Street 1:585 W 500 S STE 200
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8321
Practice Address - Country:US
Practice Address - Phone:801-990-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist