Provider Demographics
NPI:1841595055
Name:CLARK, LATRISHA
Entity Type:Individual
Prefix:MS
First Name:LATRISHA
Middle Name:
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 1:8912 VOLUNTEER LN
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3221
Mailing Address - Country:US
Mailing Address - Phone:916-344-0199
Mailing Address - Fax:
Practice Address - Street 1:212 I ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4213
Practice Address - Country:US
Practice Address - Phone:530-601-5959
Practice Address - Fax:916-287-4679
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor