Provider Demographics
NPI:1578132601
Name:CLARK-MCKNIGHT, GENA L (PHD)
Entity Type:Individual
Prefix:DR
First Name:GENA
Middle Name:L
Last Name:CLARK-MCKNIGHT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 SYLVAN WAY APT 1507
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4734
Mailing Address - Country:US
Mailing Address - Phone:262-416-4208
Mailing Address - Fax:
Practice Address - Street 1:2080 SYLVAN WAY APT 1507
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4734
Practice Address - Country:US
Practice Address - Phone:262-416-4208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty