Provider Demographics
NPI:1134550338
Name:BLACK, DANIEL PAUL (RRW)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:PAUL
Last Name:BLACK
Suffix:
Gender:M
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 S STONEMAN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-5161
Mailing Address - Country:US
Mailing Address - Phone:925-848-6937
Mailing Address - Fax:
Practice Address - Street 1:540 S EREMLAND DR
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3186
Practice Address - Country:US
Practice Address - Phone:626-966-1577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW7051101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)