Provider Demographics
NPI:1891046272
Name:BLACK, KAREN G (LMFT)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:G
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90128106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90128OtherSTATE OF CA DEPARTMENT OF CONSUMER AFFAIRS