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General NPI Number Information
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NPI Number | 1508061615
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Entity Type | Individual
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Provider Name | ELIZABETH CLARK
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Gender | Female
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Dates
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Enumeration Date | 06/19/2007
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Last Update Date | 06/16/2014
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Provider Practice Location Address
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Address Line | 780 E GILBERT ST SUITE 23 & 24
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City | SAN BERNARDINO
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State | CA
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Zip | 92415-1003
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Country | US
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Telephone | 909-387-7458
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Fax |
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Provider Business Mailing Address
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Address Line | 4369 SIERRA AVE
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City | NORCO
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State | CA
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Zip | 92860-1347
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Country | US
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Telephone | 909-387-7458
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Fax |
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 01-047276
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License Number State | CA
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