MEDICARE: MR. JAMES ROBERT CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor		NV
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1790505154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES ROBERT CLARK

Provider Business Mailing Address
First Line	:	14500 ROSCOE BLVD
Second Line	:	SUITE 400
City	:	PANORAMA CITY
State	:	CA
Zip	:	91402
Country	:	US
Telephone Number	:	818-741-2906
Fax Number	:

Provider Business Practice Location Address
First Line	:	14500 ROSCOE BLVD
Second Line	:	SUITE 400
City	:	PANORAMA CITY
State	:	CA
Zip	:	91402
Country	:	US
Telephone Number	:	818-741-2906
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2024
Last Update Date	:	02/02/2026

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