Healthcare Provider Details

I. General information

NPI: 1740514470
Provider Name (Legal Business Name): MICHAEL CLARK LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 10/13/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27127 CALLE ARROYO
SAN JUAN CAPISTRANO CA
92675-2765
US

IV. Provider business mailing address

1555 PARKMOOR AVE
SAN JOSE CA
95128-2407
US

V. Phone/Fax

Practice location:
  • Phone: 949-661-6753
  • Fax: 949-661-6853
Mailing address:
  • Phone: 408-282-0402
  • Fax: 408-282-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: