Provider Demographics
NPI:1508331257
Name:BLACK, CAROLYN LASTRA (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:LASTRA
Last Name:BLACK
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:LASTRA
Other - Last Name:RAFFEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1555 S HAVANA ST UNIT F-336
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-5004
Mailing Address - Country:US
Mailing Address - Phone:720-515-4291
Mailing Address - Fax:
Practice Address - Street 1:1555 S HAVANA ST UNIT F-336
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80012-5004
Practice Address - Country:US
Practice Address - Phone:720-515-4291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2024-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0006222103T00000X, 103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health