Provider Demographics
NPI:1043828619
Name:BLACK, BOBBY LEE (CADC-1, CRM, QMHA-R)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:LEE
Last Name:BLACK
Suffix:
Gender:M
Credentials:CADC-1, CRM, QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3647 HIGHWAY 39
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-2612
Mailing Address - Country:US
Mailing Address - Phone:541-884-5244
Mailing Address - Fax:
Practice Address - Street 1:3647 HIGHWAY 39
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-2612
Practice Address - Country:US
Practice Address - Phone:541-884-5244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No175T00000XOther Service ProvidersPeer Specialist