Provider Demographics
NPI:1275297491
Name:CLARK, SERENAH VALKYRIE CHALEARNSON
Entity Type:Individual
Prefix:
First Name:SERENAH
Middle Name:VALKYRIE CHALEARNSON
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 1:1450 N LAKE AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-2388
Mailing Address - Country:US
Mailing Address - Phone:626-794-1161
Mailing Address - Fax:
Practice Address - Street 1:1450 N LAKE AVE STE 150
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2388
Practice Address - Country:US
Practice Address - Phone:626-794-1161
Practice Address - Fax:626-794-6071
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)