Healthcare Provider Details

I. General information

NPI: 1659374775
Provider Name (Legal Business Name): MARY MCGINN CLARK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10981 SAN DIEGO MISSION RD STE 114
SAN DIEGO CA
92108-2448
US

IV. Provider business mailing address

10981 SAN DIEGO MISSION RD STE 114
SAN DIEGO CA
92108-2448
US

V. Phone/Fax

Practice location:
  • Phone: 619-280-0285
  • Fax: 619-280-0286
Mailing address:
  • Phone: 619-280-0285
  • Fax: 619-280-0286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY 17897
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 17748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: