Basic Information
| Provider Information | |||||||||
| NPI: | 1205377363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DANIELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6366 ESTRELA LN | ||||||||
| Address2: | |||||||||
| City: | MIRA LOMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917527311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512854402 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3576 ARLINGTON AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925063907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517829577 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2017 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 3387 | 05 | CA | MEDICAID |