Basic Information
| Provider Information | |||||||||
| NPI: | 1629010533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 511347 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900517902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196310128 | ||||||||
| FaxNumber: | 6196310153 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 E 4TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NATIONAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196310128 | ||||||||
| FaxNumber: | 6196310153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 03/28/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY10061 | CA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.