Provider Demographics
NPI:1568950764
Name:CLARK, PHILLIP A
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 BROCKHURST ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-4222
Mailing Address - Country:US
Mailing Address - Phone:510-923-9600
Mailing Address - Fax:510-923-9606
Practice Address - Street 1:925 BROCKHURST ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-4222
Practice Address - Country:US
Practice Address - Phone:510-923-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1962601666Medicaid