Basic Information
| Provider Information | |||||||||
| NPI: | 1407108814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | JANIE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 W 38TH ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787316405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123243315 | ||||||||
| FaxNumber: | 5123243314 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 W 38TH ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787316405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123243315 | ||||||||
| FaxNumber: | 5123243314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2012 | ||||||||
| LastUpdateDate: | 01/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 36256 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 325199302 | 05 | TX | MEDICAID | 325199301 | 05 | TX | MEDICAID |