Provider Demographics
NPI:1790791796
Name:CLAYCOMB, MARK E (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:CLAYCOMB
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 NEW MONTGOMERY ST
Mailing Address - Street 2:#420
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94105
Mailing Address - Country:US
Mailing Address - Phone:415-522-7400
Mailing Address - Fax:445-543-1932
Practice Address - Street 1:55 NEW MONTGOMERY ST
Practice Address - Street 2:#420
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105
Practice Address - Country:US
Practice Address - Phone:415-522-7400
Practice Address - Fax:445-543-1932
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS135532103T00000X
CALCS13553104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
P27568Medicare UPIN
CAZZZ2047ZMedicare ID - Type Unspecified