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General NPI Number Information
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NPI Number | 1376263319
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Entity Type | Organization
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Legal Business Name | KELLI CLARK LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 08/30/2022
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Last Update Date | 08/30/2022
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Provider Practice Location Address
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Address Line | 3150 18TH ST STE 350
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City | SAN FRANCISCO
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State | CA
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Zip | 94110-2077
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Country | US
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Telephone | 415-562-4156
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Fax | 415-952-9565
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Provider Business Mailing Address
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Address Line | 3150 18TH ST STE 350 MAILBOX#202
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City | SAN FRANCISCO
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State | CA
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Zip | 94110-2075
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Country | US
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Telephone | 415-562-4156
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Fax | 415-952-9565
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Authorized Official
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Title or Position | OPERATIONS
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Name | MR. JULIO LAGOS
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Credential | LCSW
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Telephone | 415-562-4156
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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