Provider Demographics
NPI:1386857670
Name:CLARK, FLORENCE TACY
Entity Type:Individual
Prefix:
First Name:FLORENCE
Middle Name:TACY
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 D ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-2571
Mailing Address - Country:US
Mailing Address - Phone:925-754-3673
Mailing Address - Fax:925-754-2002
Practice Address - Street 1:1915 D ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-2571
Practice Address - Country:US
Practice Address - Phone:925-754-3673
Practice Address - Fax:925-754-2002
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA07553OtherBRENTWOOD ADOL TX
CA07533OtherADOL TX - ANTIOCH
CA07536OtherDMC ADOL ANTIOCH
CA07552OtherDMC ADULT BRENTWOOD
CA07556OtherBYRON RANCH
CA070753OtherMASTER PROVIDER NUMBER
CA0753OtherDRUG MEDI-CAL BILLING NUM
CA07531OtherADULT TX - ANTIOCH
CA07551OtherADULT TX - BWD
CA070726OtherMASTER PROVIDER NUMBER
CA0726OtherDRUG M/CAL BILLING NUMBER
CA07534OtherDMC ADULT ANTIOCH
CA07555OtherDRUG CT
CA07557OtherDMC ADOL BRENTWOOD
CA56678OtherSTAFF ID NUMBER