=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467358416
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARK SUGABO LPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2026
-----------------------------------------------------
Last Update Date | 10/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1922 THE ALAMEDA STE 316
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95126-1461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-261-7777
-----------------------------------------------------
Fax | 408-642-6052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1257 BLUFF AVE
-----------------------------------------------------
City | KING CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93930-3631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-644-6539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 167G00000X
-----------------------------------------------------
Taxonomy Name | Licensed Psychiatric Technician
-----------------------------------------------------
License Number | 43422
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------