Provider Demographics
NPI:1578798278
Name:CLARK, MITCHELL BRADY (MS)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:BRADY
Last Name:CLARK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 MISSION GORGE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3425
Mailing Address - Country:US
Mailing Address - Phone:619-282-2232
Mailing Address - Fax:619-282-2992
Practice Address - Street 1:6160 MISSION GORGE RD STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3425
Practice Address - Country:US
Practice Address - Phone:619-282-2232
Practice Address - Fax:619-282-2992
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WARC00050738101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health