Provider Demographics
NPI:1356440275
Name:CLARK, JUDITH Z (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:Z
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO 100 PMB 470
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0100
Mailing Address - Country:US
Mailing Address - Phone:760-924-8503
Mailing Address - Fax:760-924-0541
Practice Address - Street 1:126 OLD MAMMOTH RD
Practice Address - Street 2:SUITE 214
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546
Practice Address - Country:US
Practice Address - Phone:760-924-8503
Practice Address - Fax:760-924-0541
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13963103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11413861OtherAETNA
CAPSY139630Medicaid
CACP13963OtherMEDICARE PTAN
CACP13963OtherMEDICARE PTAN
R94124Medicare UPIN