Provider Demographics
NPI:1518300946
Name:BLACK, PEGGY SUE (LPCC, LCPC)
Entity type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:SUE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LPCC, LCPC
Other - Prefix:MRS
Other - First Name:PEGGY
Other - Middle Name:SUE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC, LCPC
Mailing Address - Street 1:5060 SHOREHAM PL STE 330
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5976
Mailing Address - Country:US
Mailing Address - Phone:877-840-6956
Mailing Address - Fax:619-383-6701
Practice Address - Street 1:5060 SHOREHAM PL STE 330
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5976
Practice Address - Country:US
Practice Address - Phone:877-840-6956
Practice Address - Fax:619-383-6701
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV00464-LC101YA0400X
NVCP-0215101YP2500X, 225400000X
CALPCC15039101YM0800X
NV00184-LCS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1518300946Medicaid