Provider Demographics
NPI:1578903175
Name:CLACK, ANDREW PAUL (MA)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:PAUL
Last Name:CLACK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MR
Other - First Name:ANDY
Other - Middle Name:PAUL
Other - Last Name:CLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:9330 BASELINE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5827
Mailing Address - Country:US
Mailing Address - Phone:951-235-2372
Mailing Address - Fax:909-981-2210
Practice Address - Street 1:9330 BASELINE RD STE 102
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91701
Practice Address - Country:US
Practice Address - Phone:951-235-2372
Practice Address - Fax:909-981-2210
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96297106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist