MEDICARE: MS. SALLY A CLARK MFT

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	106H00000X	Marriage & Family Therapist	33352	CA

General Provider Information

NPI Number	:	1609498211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SALLY A CLARK MFT

Provider Business Mailing Address
First Line	:	2462 ALVIN ST
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94043
Country	:	US
Telephone Number	:	510-549-9401
Fax Number	:

Provider Business Practice Location Address
First Line	:	2462 ALVIN ST
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94043
Country	:	US
Telephone Number	:	510-549-9401
Fax Number	:

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

Provider Enumeration Date	:	05/18/2020
Last Update Date	:	05/18/2020

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