Healthcare Provider Details

I. General information

NPI: 1902072911
Provider Name (Legal Business Name): SUSAN ELIZABETH CLARK M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY # MC5014
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

3020 CHILDRENS WAY # MC5014
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-576-1700
  • Fax: 858-278-2365
Mailing address:
  • Phone: 858-576-1700
  • Fax: 858-278-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSB33147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: