Provider Demographics
NPI:1629583471
Name:BLACK, ROBERT D (LPC, CRC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:BLACK
Suffix:
Gender:M
Credentials:LPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 N DARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1600
Mailing Address - Country:US
Mailing Address - Phone:626-628-7373
Mailing Address - Fax:
Practice Address - Street 1:518 N DARWOOD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1600
Practice Address - Country:US
Practice Address - Phone:626-628-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007406101YP2500X
CA108223225C00000X
GA108223225C00000X
CALPC308101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor