Provider Demographics
NPI:1629193610
Name:CLARK, MARGARET LOUISE (PHD)
Entity Type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:LOUISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4026 PECK RD
Mailing Address - Street 2:#204
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-2247
Mailing Address - Country:US
Mailing Address - Phone:626-444-0539
Mailing Address - Fax:626-444-7990
Practice Address - Street 1:4026 PECK RD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-2247
Practice Address - Country:US
Practice Address - Phone:626-444-0539
Practice Address - Fax:626-444-7990
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 16603103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACLA0716OtherSTAFF CODE