Healthcare Provider Details

I. General information

NPI: 1700373875
Provider Name (Legal Business Name): CHANELL CLARK MAS-MFT, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHANELL CLARK-CLUFF MAS-MFT, LMFT

II. Dates (important events)

Enumeration Date: 04/15/2018
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E PLAZA CIR STE 6
LITCHFIELD PARK AZ
85340-4909
US

IV. Provider business mailing address

13590 W CYPRESS ST
GOODYEAR AZ
85395-2424
US

V. Phone/Fax

Practice location:
  • Phone: 602-799-4385
  • Fax:
Mailing address:
  • Phone: 602-799-4385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number10367
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: