MEDICARE: MR. MITCHELL BRADY CLARK M.S.

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	171M00000X	Case Manager/Care Coordinator
2	101YM0800X	Mental Health Counselor	RC00050738	WA

General Provider Information

NPI Number	:	1578798278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MITCHELL BRADY CLARK M.S.

Provider Business Mailing Address
First Line	:	6160 MISSION GORGE RD STE 120
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3425
Country	:	US
Telephone Number	:	619-282-2232
Fax Number	:	619-282-2992

Provider Business Practice Location Address
First Line	:	6160 MISSION GORGE RD STE 120
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3425
Country	:	US
Telephone Number	:	619-282-2232
Fax Number	:	619-282-2992

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2009
Last Update Date	:	09/24/2024

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