Provider Demographics
NPI:1003373713
Name:BLACK, ROBERT WILLIAM (LPPC 17770)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:BLACK
Suffix:
Gender:M
Credentials:LPPC 17770
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5070
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92165-5070
Mailing Address - Country:US
Mailing Address - Phone:619-840-5386
Mailing Address - Fax:
Practice Address - Street 1:4391 ELM ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5221
Practice Address - Country:US
Practice Address - Phone:619-840-5386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17770101YP2500X
390200000X
CAAPCC8336101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program