MEDICARE: DEIERHOI-CLARK PSYCHOLOGY, A PROFESSIONAL ORGANIZATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1306534219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEIERHOI-CLARK PSYCHOLOGY, A PROFESSIONAL ORGANIZATION

Provider Business Mailing Address
First Line	:	2535 KETTNER BLVD STE 2B1
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1253
Country	:	US
Telephone Number	:	619-512-9451
Fax Number	:	619-821-9721

Provider Business Practice Location Address
First Line	:	2535 KETTNER BLVD STE 2B1
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1253
Country	:	US
Telephone Number	:	619-512-9451
Fax Number	:	619-821-9721

Authorized Official
Title or Position	:	OWNER/PSYCHOLOGIST
Name	:	DR. CLARIE EMILY DEIERHOI-CLARK
Credential	:	PHD
Telephone Number	:	619-512-9451

Provider Enumeration Date	:	04/27/2023
Last Update Date	:	04/27/2023

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