Basic Information
| Provider Information | |||||||||
| NPI: | 1033674718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | TOM | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 838 BEACH COURT | ||||||||
| Address2: | |||||||||
| City: | LOTUS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165088722 | ||||||||
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| Practice Location | |||||||||
| Address1: | 838 BEACH COURT | ||||||||
| Address2: | |||||||||
| City: | LOTUS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956339563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306267252 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2019 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 1356560719 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1043542707 | 05 | CA | MEDICAID |