Provider Demographics
NPI:1790059269
Name:CLARK, FRED ALLEN (PHD, LMFT)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:ALLEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162550
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-2550
Mailing Address - Country:US
Mailing Address - Phone:916-688-0801
Mailing Address - Fax:916-688-0801
Practice Address - Street 1:2701 COTTAGE WAY
Practice Address - Street 2:38
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-1225
Practice Address - Country:US
Practice Address - Phone:916-481-2071
Practice Address - Fax:916-688-0801
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3605101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health