Provider Demographics
NPI:1205377363
Name:CLARK, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6366 ESTRELA LN
Mailing Address - Street 2:
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-7311
Mailing Address - Country:US
Mailing Address - Phone:951-285-4402
Mailing Address - Fax:
Practice Address - Street 1:3576 ARLINGTON AVE STE 102
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3907
Practice Address - Country:US
Practice Address - Phone:951-782-9577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3387Medicaid