Provider Demographics
NPI:1568051225
Name:CLARK, CRYSTAL (MS)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 OCEAN PARK BLVD # 145
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3004
Mailing Address - Country:US
Mailing Address - Phone:910-551-2166
Mailing Address - Fax:
Practice Address - Street 1:3019 OCEAN PARK BLVD # 145
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3004
Practice Address - Country:US
Practice Address - Phone:818-538-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA137600106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist