Healthcare Provider Details

I. General information

NPI: 1093225153
Provider Name (Legal Business Name): JAMES WILLIAM CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 05/07/2024
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11015 BLOOMFIELD AVE
SANTA FE SPRINGS CA
90670-4601
US

IV. Provider business mailing address

11015 BLOOMFIELD AVE
SANTA FE SPRINGS CA
90670-4601
US

V. Phone/Fax

Practice location:
  • Phone: 562-906-2676
  • Fax:
Mailing address:
  • Phone: 562-906-2676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: