Provider Demographics
NPI:1700366754
Name:CLARK, KARALEE J
Entity Type:Individual
Prefix:
First Name:KARALEE
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2684 DUVAL RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8231
Mailing Address - Country:US
Mailing Address - Phone:805-402-2094
Mailing Address - Fax:
Practice Address - Street 1:1911 WILLIAMS DR STE 200
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0673
Practice Address - Country:US
Practice Address - Phone:805-981-6830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program