Healthcare Provider Details

I. General information

NPI: 1336134527
Provider Name (Legal Business Name): MARTINA ANN CLARKE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 SPRING ST STE 204 #204
LA MESA CA
91941-5273
US

IV. Provider business mailing address

4700 SPRING ST #204
LA MESA CA
91942-5273
US

V. Phone/Fax

Practice location:
  • Phone: 619-583-0747
  • Fax: 619-583-2729
Mailing address:
  • Phone: 619-583-0747
  • Fax: 619-583-2729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY18345
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: