Provider Demographics
NPI:1205250529
Name:BLACK, IRIS ETON (MA,MFCT)
Entity type:Individual
Prefix:MS
First Name:IRIS
Middle Name:ETON
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA,MFCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3558 MANDEVILLE CANYON RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-1022
Mailing Address - Country:US
Mailing Address - Phone:310-476-8911
Mailing Address - Fax:310-476-8911
Practice Address - Street 1:3558 MANDEVILLE CANYON RD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-1022
Practice Address - Country:US
Practice Address - Phone:310-476-8911
Practice Address - Fax:310-476-8911
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMA021203106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist