Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | ||
Y | 101YM0800X | Mental Health Counselor | APCC8336 | CA |
NPI | 1003373713 |
---|---|
Provider Name | Robert William Black |
First Address | San Diego, CA 92102-4550 |
Second Address | San Diego, CA 92102-4550 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/02/2019 |
Last Update Date | 24/09/2020 |