Provider Demographics
NPI:1215402284
Name:CLARK, JULIE ALYSIA (RADT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ALYSIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-3512
Mailing Address - Country:US
Mailing Address - Phone:916-929-1951
Mailing Address - Fax:916-929-5116
Practice Address - Street 1:310 HARRIS AVE STE A
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3249
Practice Address - Country:US
Practice Address - Phone:916-649-6793
Practice Address - Fax:916-929-7411
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1322980918101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1322980918OtherCCAPP