Provider Demographics
NPI:1174392666
Name:BLACK, ELIZABETH LESLIE (LMFT, PHD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:LESLIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-0131
Mailing Address - Country:US
Mailing Address - Phone:415-689-0704
Mailing Address - Fax:
Practice Address - Street 1:301 HARTZ AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526
Practice Address - Country:US
Practice Address - Phone:925-232-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT138994106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist