Provider Demographics
NPI:1356650162
Name:CLARK, SUSAN LYNN (MS, COUNSELING, MFT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, COUNSELING, MFT
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:LYNN
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, COUNSELING, MFT
Mailing Address - Street 1:11148 BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6915
Mailing Address - Country:US
Mailing Address - Phone:530-798-8215
Mailing Address - Fax:530-271-0775
Practice Address - Street 1:11148 BUTLER RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6915
Practice Address - Country:US
Practice Address - Phone:530-798-8215
Practice Address - Fax:530-271-0775
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 18395106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist