Provider Demographics
NPI:1962848093
Name:BLACK, STEPHEN LEON (SUDCC-III)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:LEON
Last Name:BLACK
Suffix:
Gender:
Credentials:SUDCC-III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CROWN POINT CIR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9561
Mailing Address - Country:US
Mailing Address - Phone:530-273-5440
Mailing Address - Fax:
Practice Address - Street 1:500 CROWN POINT CIR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9561
Practice Address - Country:US
Practice Address - Phone:530-273-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1006171257101YA0400X
CA156325 I101YA0400X
CA7537101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)