Provider Demographics
NPI:1821164807
Name:CLARKE, DYAN LEE (MFT)
Entity Type:Individual
Prefix:MS
First Name:DYAN
Middle Name:LEE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3513 FIELDCREST CT
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-4823
Mailing Address - Country:US
Mailing Address - Phone:916-632-1356
Mailing Address - Fax:
Practice Address - Street 1:609 OAK ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-3245
Practice Address - Country:US
Practice Address - Phone:916-789-2293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT37633106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist