Provider Demographics
NPI:1336134527
Name:CLARKE, MARTINA ANN (PSYD)
Entity Type:Individual
Prefix:MS
First Name:MARTINA
Middle Name:ANN
Last Name:CLARKE
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 1:4700 SPRING ST #204
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-5273
Mailing Address - Country:US
Mailing Address - Phone:619-583-0747
Mailing Address - Fax:619-583-2729
Practice Address - Street 1:4700 SPRING ST STE 204
Practice Address - Street 2:#204
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5273
Practice Address - Country:US
Practice Address - Phone:619-583-0747
Practice Address - Fax:619-583-2729
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18345103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling