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General NPI Number Information
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NPI Number | 1043368145
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Entity Type | Individual
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Provider Name | ELISABETH OLIVER CLARK PH.D.
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Gender | Female
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 544 S SAN VICENTE BLVD SUITE 203
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City | LOS ANGELES
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State | CA
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Zip | 90048-4622
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Country | US
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Telephone | 323-850-0620
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Fax |
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Provider Business Mailing Address
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Address Line | 1558 N OGDEN DR
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City | LOS ANGELES
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State | CA
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Zip | 90046-2616
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Country | US
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Telephone | 323-850-0620
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Fax | 323-850-0620
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY12291
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License Number State | CA
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