Provider Demographics
NPI:1689927824
Name:CLARK, TWILA B (PHD)
Entity Type:Individual
Prefix:
First Name:TWILA
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TWILA
Other - Middle Name:B
Other - Last Name:BERGET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:17595 HARVARD AVE STE C
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-8522
Mailing Address - Country:US
Mailing Address - Phone:714-615-9308
Mailing Address - Fax:
Practice Address - Street 1:17595 HARVARD AVE STE C
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-8522
Practice Address - Country:US
Practice Address - Phone:714-615-9308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22187103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical