Healthcare Provider Details

I. General information

NPI: 1306534219
Provider Name (Legal Business Name): DEIERHOI-CLARK PSYCHOLOGY, A PROFESSIONAL ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 KETTNER BLVD STE 2B1
SAN DIEGO CA
92101-1253
US

IV. Provider business mailing address

2535 KETTNER BLVD STE 2B1
SAN DIEGO CA
92101-1253
US

V. Phone/Fax

Practice location:
  • Phone: 619-512-9451
  • Fax: 619-821-9721
Mailing address:
  • Phone: 619-512-9451
  • Fax: 619-821-9721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CLARIE EMILY DEIERHOI-CLARK
Title or Position: OWNER/PSYCHOLOGIST
Credential: PHD
Phone: 619-512-9451