Provider Demographics
NPI:1558600213
Name:CLARK, BROOKE DANIELLE (PPS, MFTI)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:DANIELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PPS, MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 ELDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:91342-6506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11600 ELDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:LAKE VIEW TERRACE
Practice Address - State:CA
Practice Address - Zip Code:91342-6506
Practice Address - Country:US
Practice Address - Phone:818-686-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 71502106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist