Basic Information
| Provider Information | |||||||||
| NPI: | 1942869011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | SERENA | ||||||||
| MiddleName: | ADRIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 995 GATEWAY CENTER WAY, SUITE 300 SAN DIEGO, CA 92102 | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193982156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1180 THIRD AVE STE C3 | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919113139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196918164 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.