Provider Demographics
NPI:1104116870
Name:DAN BLACK ENTERPRISES INC
Entity type:Organization
Organization Name:DAN BLACK ENTERPRISES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:SPENCER
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:CBA/FL
Authorized Official - Phone:954-290-9282
Mailing Address - Street 1:6030 NW 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-3272
Mailing Address - Country:US
Mailing Address - Phone:954-290-9282
Mailing Address - Fax:561-853-2195
Practice Address - Street 1:6030 NW 42ND AVE
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-3272
Practice Address - Country:US
Practice Address - Phone:954-290-9282
Practice Address - Fax:561-853-2195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0833103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL676044996Medicaid
FL676044996Medicaid