Provider Demographics
NPI:1831416460
Name:BLACK, BECKY E (RD)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:E
Last Name:BLACK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1772 SANTA CRUZ ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3352
Mailing Address - Country:US
Mailing Address - Phone:949-290-4016
Mailing Address - Fax:
Practice Address - Street 1:1772 SANTA CRUZ ST
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-3352
Practice Address - Country:US
Practice Address - Phone:949-290-4016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA709236133V00000X
CA36620106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1831416460OtherNOT SURE HOW TO ANSWER THIS