Provider Demographics
NPI:1700924453
Name:BLACK, ELVIA RIVERA (LCDC)
Entity Type:Individual
Prefix:MS
First Name:ELVIA
Middle Name:RIVERA
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:MS
Other - First Name:ELVIA
Other - Middle Name:TARIN
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-445-7787
Mailing Address - Fax:512-440-4059
Practice Address - Street 1:1643 E 2ND ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4411
Practice Address - Country:US
Practice Address - Phone:512-804-3659
Practice Address - Fax:512-804-3677
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7953101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)