Provider Demographics
NPI:1629092127
Name:CLARKE, KATHARINE ANN (PT & PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:KATHARINE
Middle Name:ANN
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PT & PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25401 CABOT RD STE 116
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5530
Mailing Address - Country:US
Mailing Address - Phone:949-454-0440
Mailing Address - Fax:949-454-0541
Practice Address - Street 1:25401 CABOT RD STE 116
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5530
Practice Address - Country:US
Practice Address - Phone:949-454-0440
Practice Address - Fax:949-454-0541
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 14015103T00000X
CAPT 7151225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP14015Medicare ID - Type UnspecifiedPSYCHOLOGIST