Provider Demographics
NPI:1104129840
Name:BLACK, KATHRYN R (LAC, MT-BC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:LAC, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1966 TICE VALLEY BLVD # 228
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595-2203
Mailing Address - Country:US
Mailing Address - Phone:480-818-4277
Mailing Address - Fax:
Practice Address - Street 1:2258 SANTA CLARA AVE STE 1
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4473
Practice Address - Country:US
Practice Address - Phone:510-814-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17203171100000X
UT08011225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist