Provider Demographics
NPI:1093028870
Name:CLARK, EDWARD DERBY I
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:DERBY
Last Name:CLARK
Suffix:I
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 1:1355 PEBBLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-1612
Mailing Address - Country:US
Mailing Address - Phone:916-289-9380
Mailing Address - Fax:916-441-1758
Practice Address - Street 1:1355 PEBBLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833-1612
Practice Address - Country:US
Practice Address - Phone:916-289-9380
Practice Address - Fax:916-441-1758
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)