Provider Demographics
NPI:1982332623
Name:ELROD-BLACK, EMILY (MA, APCC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:ELROD-BLACK
Suffix:
Gender:F
Credentials:MA, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-3734
Mailing Address - Country:US
Mailing Address - Phone:650-207-3557
Mailing Address - Fax:
Practice Address - Street 1:1181 MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-2005
Practice Address - Country:US
Practice Address - Phone:650-207-3557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12004101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12004OtherBBS APCC