Provider Demographics
NPI:1457534026
Name:BLACK, FREDDIE DE ANDREA
Entity Type:Individual
Prefix:MS
First Name:FREDDIE
Middle Name:DE ANDREA
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21707 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-7009
Mailing Address - Country:US
Mailing Address - Phone:310-543-9900
Mailing Address - Fax:310-543-9910
Practice Address - Street 1:21707 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-7009
Practice Address - Country:US
Practice Address - Phone:310-543-9900
Practice Address - Fax:310-543-9910
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA52400106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist