Basic Information
| Provider Information | |||||||||
| NPI: | 1104116870 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAN BLACK ENTERPRISES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6030 NW 42ND AVE | ||||||||
| Address2: | |||||||||
| City: | COCONUT CREEK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330733272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542909282 | ||||||||
| FaxNumber: | 5618532195 | ||||||||
| Practice Location | |||||||||
| Address1: | 6030 NW 42ND AVE | ||||||||
| Address2: | |||||||||
| City: | COCONUT CREEK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330733272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542909282 | ||||||||
| FaxNumber: | 5618532195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2011 | ||||||||
| LastUpdateDate: | 06/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | BLACK | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | SPENCER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9542909282 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CBA/FL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0833 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 676044996 | 05 | FL | MEDICAID |