Provider Demographics
NPI:1700230737
Name:BLACK, TIMOTHY SCOTT (LMSW)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:SCOTT
Last Name:BLACK
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9304 FOREST LN
Mailing Address - Street 2:SUITE 161 NORTH
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-6238
Mailing Address - Country:US
Mailing Address - Phone:214-342-5800
Mailing Address - Fax:
Practice Address - Street 1:9304 FOREST LN
Practice Address - Street 2:SUITE 161 NORTH
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-6238
Practice Address - Country:US
Practice Address - Phone:214-342-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24658104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker