MEDICARE: JUSTIN CLARKE LCSW 128480

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	104100000X	Social Worker	103389	CA
2	1041C0700X	Clinical Social Worker	128480	CA

General Provider Information

NPI Number	:	1679027452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN CLARKE LCSW 128480

Provider Business Mailing Address
First Line	:	PO BOX 1654
Second Line	:
City	:	TEMPLETON
State	:	CA
Zip	:	93465-1654
Country	:	US
Telephone Number	:	805-461-6072
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 NIBLICK RD
Second Line	:
City	:	PASO ROBLES
State	:	CA
Zip	:	93446-4858
Country	:	US
Telephone Number	:	805-769-1000
Fax Number	:

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

Provider Enumeration Date	:	08/09/2016
Last Update Date	:	03/31/2026

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