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General NPI Number Information
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NPI Number | 1609050913
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Entity Type | Individual
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Provider Name | KIMBERLY IRENE CLARK MFT
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Gender | Female
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Dates
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Enumeration Date | 12/21/2007
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Last Update Date | 12/21/2007
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Provider Practice Location Address
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Address Line | 3077 COOLIDGE AVE
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City | COSTA MESA
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State | CA
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Zip | 92626-2809
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Country | US
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Telephone | 714-614-7382
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Fax | 714-444-0722
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Provider Business Mailing Address
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Address Line | 3077 COOLIDGE AVE
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City | COSTA MESA
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State | CA
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Zip | 92626-2809
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Country | US
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Telephone | 714-614-7382
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Fax | 714-444-0722
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 40815
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License Number State | CA
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