Basic Information
| Provider Information | |||||||||
| NPI: | 1891821278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | JANET | ||||||||
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| Credential: | CATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E PARK AVE UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934546247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053490323 | ||||||||
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| Practice Location | |||||||||
| Address1: | 412 E TUNNELL ST # B | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934544146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059250315 | ||||||||
| FaxNumber: | 8053461787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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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) |
No ID Information.