Healthcare Provider Details

I. General information

NPI: 1376263319
Provider Name (Legal Business Name): KELLI CLARK LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 18TH ST STE 350
SAN FRANCISCO CA
94110-2077
US

IV. Provider business mailing address

3150 18TH ST STE 350 MAILBOX#202
SAN FRANCISCO CA
94110-2075
US

V. Phone/Fax

Practice location:
  • Phone: 415-562-4156
  • Fax: 415-952-9565
Mailing address:
  • Phone: 415-562-4156
  • Fax: 415-952-9565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JULIO LAGOS
Title or Position: OPERATIONS
Credential: LCSW
Phone: 415-562-4156