Provider Demographics
NPI:1093738882
Name:CLARK, MARCIA (MFT)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 E CAMPBELL AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2143
Mailing Address - Country:US
Mailing Address - Phone:408-404-6968
Mailing Address - Fax:408-404-6968
Practice Address - Street 1:653 E CAMPBELL AVE STE 3
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2143
Practice Address - Country:US
Practice Address - Phone:408-404-6968
Practice Address - Fax:408-404-6968
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 36013106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist