Provider Demographics
NPI:1376263319
Name:KELLI CLARK LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KELLI CLARK LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGOS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:415-562-4156
Mailing Address - Street 1:3150 18TH ST STE 350
Mailing Address - Street 2:MAILBOX#202
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-2075
Mailing Address - Country:US
Mailing Address - Phone:415-562-4156
Mailing Address - Fax:415-952-9565
Practice Address - Street 1:3150 18TH ST STE 350
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2077
Practice Address - Country:US
Practice Address - Phone:415-562-4156
Practice Address - Fax:415-952-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty