Provider Demographics
NPI:1326061813
Name:JOHNSON CLARK, KINA ANNETTE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KINA
Middle Name:ANNETTE
Last Name:JOHNSON CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KINA
Other - Middle Name:ANNETTE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1380 LEAD HILL BLVD
Mailing Address - Street 2:#110
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2941
Mailing Address - Country:US
Mailing Address - Phone:916-532-0996
Mailing Address - Fax:916-786-3080
Practice Address - Street 1:1380 LEAD HILL BLVD
Practice Address - Street 2:#110
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2941
Practice Address - Country:US
Practice Address - Phone:916-726-4030
Practice Address - Fax:916-786-3080
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16066103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PL160660Medicare ID - Type Unspecified