Provider Demographics
NPI:1528671674
Name:TODD BLACK LICENSED MARRIAGE AND FAMILY THERAPIST PC
Entity type:Organization
Organization Name:TODD BLACK LICENSED MARRIAGE AND FAMILY THERAPIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:650-260-8564
Mailing Address - Street 1:120 N EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2791
Mailing Address - Country:US
Mailing Address - Phone:650-260-8564
Mailing Address - Fax:
Practice Address - Street 1:120 N EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2791
Practice Address - Country:US
Practice Address - Phone:650-260-8564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)