Provider Demographics
NPI:1386640159
Name:BLACK, DAVID L (PSYD, LCSW)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:BLACK
Suffix:
Gender:M
Credentials:PSYD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1531 E BRADFORD PKWY
Mailing Address - Street 2:STE 210-4
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6566
Mailing Address - Country:US
Mailing Address - Phone:417-890-4083
Mailing Address - Fax:417-890-4091
Practice Address - Street 1:1531 E BRADFORD PKWY
Practice Address - Street 2:STE 210-4
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6566
Practice Address - Country:US
Practice Address - Phone:417-890-4083
Practice Address - Fax:417-890-4091
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010042841041C0700X, 106H00000X
MO2009026793103TH0100X, 103TA0400X, 103TB0200X, 103TP2701X, 103TC1900X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494960107Medicaid
MO494960107Medicaid