Provider Demographics
NPI:1073937637
Name:CLARK, PATRICIA ANN (MFTI)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFTI
Mailing Address - Street 1:PO BOX 2587
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-0587
Mailing Address - Country:US
Mailing Address - Phone:707-527-2215
Mailing Address - Fax:
Practice Address - Street 1:429 SPEERS RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-3123
Practice Address - Country:US
Practice Address - Phone:707-571-2215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 75971106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist