Healthcare Provider Details

I. General information

NPI: 1861907149
Provider Name (Legal Business Name): YONIQUE CLARKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 TREAT BLVD
CONCORD CA
94518-3601
US

IV. Provider business mailing address

2975 TREAT BLVD C5
CONCORD CA
94518-3601
US

V. Phone/Fax

Practice location:
  • Phone: 925-219-9009
  • Fax:
Mailing address:
  • Phone: 925-219-9009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: