Provider Demographics
NPI:1598846024
Name:CLARK, ANYELLA A M (MFT)
Entity Type:Individual
Prefix:
First Name:ANYELLA
Middle Name:A M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WILSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-1031
Mailing Address - Country:US
Mailing Address - Phone:415-786-8181
Mailing Address - Fax:
Practice Address - Street 1:2 WILSHIRE AVE
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-1031
Practice Address - Country:US
Practice Address - Phone:415-786-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43180106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist