Provider Demographics
NPI:1114273570
Name:SMITH-BLACK, TAWANNA JEAN
Entity type:Individual
Prefix:MRS
First Name:TAWANNA
Middle Name:JEAN
Last Name:SMITH-BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 W 99TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-4605
Mailing Address - Country:US
Mailing Address - Phone:323-779-2296
Mailing Address - Fax:323-756-4135
Practice Address - Street 1:3281 E GUASTI RD STE 450
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7635
Practice Address - Country:US
Practice Address - Phone:909-323-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CAASW1187711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker