Healthcare Provider Details

I. General information

NPI: 1144035635
Provider Name (Legal Business Name): MICHAEL CLARK MARRIAGE AND FAMILY THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 BONITA AVE STE 208
BERKELEY CA
94704-1014
US

IV. Provider business mailing address

70 HARLAN ST APT 101
SAN LEANDRO CA
94577-5850
US

V. Phone/Fax

Practice location:
  • Phone: 510-556-5800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL ERWIN CLARK JR.
Title or Position: CEO
Credential: LMFT
Phone: 510-556-5800