Provider Demographics
NPI:1316215528
Name:CLARK, ANDREW J
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2531
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93457-2531
Mailing Address - Country:US
Mailing Address - Phone:805-268-5218
Mailing Address - Fax:
Practice Address - Street 1:1219 OAK KNOLL RD
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-4303
Practice Address - Country:US
Practice Address - Phone:805-268-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP3168103TS0200X, 101Y00000X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool