Provider Demographics
NPI:1033674718
Name:CLARK, TOM ALLEN
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:ALLEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 BEACH COURT
Mailing Address - Street 2:
Mailing Address - City:LOTUS
Mailing Address - State:CA
Mailing Address - Zip Code:95682
Mailing Address - Country:US
Mailing Address - Phone:916-508-8722
Mailing Address - Fax:
Practice Address - Street 1:838 BEACH COURT
Practice Address - Street 2:
Practice Address - City:LOTUS
Practice Address - State:CA
Practice Address - Zip Code:95633-9563
Practice Address - Country:US
Practice Address - Phone:530-626-7252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA1356560719101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1043542707Medicaid