Provider Demographics
NPI:1083015333
Name:DEIERHOI-CLARK, CLARIE EMILY (PHD)
Entity Type:Individual
Prefix:
First Name:CLARIE
Middle Name:EMILY
Last Name:DEIERHOI-CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CLAIRE
Other - Middle Name:EMILY
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2535 KETTNER BLVD STE 2B1
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1253
Mailing Address - Country:US
Mailing Address - Phone:619-512-9451
Mailing Address - Fax:
Practice Address - Street 1:2535 KETTNER BLVD STE 2B1
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1253
Practice Address - Country:US
Practice Address - Phone:619-512-9451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31224103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty