Provider Demographics
NPI:1891852471
Name:BLACK-GONZALEZ, SHELLEY DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:DIANE
Last Name:BLACK-GONZALEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14659 OLIVE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-1652
Mailing Address - Country:US
Mailing Address - Phone:818-485-0888
Mailing Address - Fax:
Practice Address - Street 1:14659 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1652
Practice Address - Country:US
Practice Address - Phone:818-485-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 183271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical