Provider Demographics
NPI:1225517006
Name:CLARK, MACKENZIE CROSIAR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:CROSIAR
Last Name:CLARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 SAN ELIJO AVE # 242
Mailing Address - Street 2:
Mailing Address - City:CARDIFF BY THE SEA
Mailing Address - State:CA
Mailing Address - Zip Code:92007
Mailing Address - Country:US
Mailing Address - Phone:619-356-8964
Mailing Address - Fax:
Practice Address - Street 1:270 N EL CAMINO REAL SUITE F518
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024
Practice Address - Country:US
Practice Address - Phone:619-356-8964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111161106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist