Provider Demographics
NPI:1962733972
Name:BLACK, ELIZABETH (LMHC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W GRIGGS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1234
Mailing Address - Country:US
Mailing Address - Phone:575-647-2800
Mailing Address - Fax:575-647-2898
Practice Address - Street 1:118 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:575-647-2896
Practice Address - Fax:575-647-2898
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0128241101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47043Medicaid