Provider Demographics
NPI:1588460463
Name:BLACK LOCUST PSYCHOLOGY PC
Entity type:Organization
Organization Name:BLACK LOCUST PSYCHOLOGY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FLACK
Authorized Official - Suffix:
Authorized Official - Credentials:JD, PHD
Authorized Official - Phone:203-208-8641
Mailing Address - Street 1:29 WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:EAST HADDAM
Mailing Address - State:CT
Mailing Address - Zip Code:06423-1204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 WICKHAM RD
Practice Address - Street 2:
Practice Address - City:EAST HADDAM
Practice Address - State:CT
Practice Address - Zip Code:06423-1204
Practice Address - Country:US
Practice Address - Phone:203-208-8641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-21
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty