Provider Demographics
NPI:1568188290
Name:CLARK, ANGELA J
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:J
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 1:8940 RACHEL FREEMAN WAY APT 4201
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-9559
Mailing Address - Country:US
Mailing Address - Phone:619-259-7664
Mailing Address - Fax:
Practice Address - Street 1:48 BISTATE PLAZA
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675
Practice Address - Country:US
Practice Address - Phone:509-768-2249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT132478106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist