Provider Demographics
NPI:1053603712
Name:BLACK, SCARLETT (PSYD, LPC)
Entity type:Individual
Prefix:MISS
First Name:SCARLETT
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 DAVID WADE DRIVE
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 DAVID WADE DRIVE
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77905
Practice Address - Country:US
Practice Address - Phone:361-574-7283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68110101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional