Healthcare Provider Details

I. General information

NPI: 1346258316
Provider Name (Legal Business Name): PATRICIA PUSEY CLARK MFT MARRIAGE AND FAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 N DUTTON S 100
SANTA ROSA CA
95401
US

IV. Provider business mailing address

659 CHERRY ST
SANTA ROSA CA
95404
US

V. Phone/Fax

Practice location:
  • Phone: 707-526-8306
  • Fax: 707-526-8319
Mailing address:
  • Phone: 707-526-8300
  • Fax: 707-526-8310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC33193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: