Provider Demographics
NPI:1093024937
Name:CLARK-TAN, ADAM G (LCSW)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:G
Last Name:CLARK-TAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PENHURST AVE
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-4423
Mailing Address - Country:US
Mailing Address - Phone:415-763-7782
Mailing Address - Fax:
Practice Address - Street 1:21 PENHURST AVE
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-4423
Practice Address - Country:US
Practice Address - Phone:415-763-7782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA635631041C0700X
OHS.0901089104100000X
CA30621104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker