Provider Demographics
NPI:1609498211
Name:CLARK, SALLY A (MFT)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:A
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 1:2462 ALVIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043
Mailing Address - Country:US
Mailing Address - Phone:510-549-9401
Mailing Address - Fax:
Practice Address - Street 1:2462 ALVIN ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043
Practice Address - Country:US
Practice Address - Phone:510-549-9401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33352106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist